A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?
Putting on sterile gloves after preparing the sterile field
Placing the supplies on the sterile field and leaving a 1-inch perimeter
Balancing the bottle on the sterile basin while pouring the liquid
Applying a sterile gown after applying a sterile mask
Answer: C.
The Correct Answer is C
A. Putting on sterile gloves after preparing the sterile field: This is correct aseptic practice, as sterile gloves should be donned after the sterile field is prepared to maintain sterility.
B. Placing the supplies on the sterile field and leaving a 1-inch perimeter: Maintaining a 1-inch border around the sterile field is standard practice to avoid contamination. Supplies placed within the field but outside this border remain sterile.
C. Balancing the bottle on the sterile basin while pouring the liquid: Placing a bottle on a sterile field risks contaminating the field if the bottle is not sterile. This action constitutes a break in surgical aseptic technique.
D. Applying a sterile gown after applying a sterile mask: Donning a mask before the sterile gown is appropriate to prevent contamination of the sterile gown during placement. This does not break aseptic technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,B,E,C,A
Explanation
Rationale:
A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.
B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.
C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.
D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.
E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.
Correct Answer is D
Explanation
A. Patient-centered care: This competency focuses on respecting client preferences, values, and needs while involving them in care decisions. Completing an incident report does not directly address individualized client care.
B. Evidence-based practice: Evidence-based practice involves integrating the best current research evidence with clinical expertise and patient values. Documenting an incident report is not based on reviewing or applying research evidence.
C. Informatics: Informatics involves using information technology to communicate, manage knowledge, and support decision-making. While an incident report may use electronic systems, the primary purpose is not focused on informatics competency.
D. Quality improvement: Completing an incident report identifies errors, near misses, or adverse events, which helps the healthcare team analyze processes and implement changes to improve patient safety. This reflects the quality improvement competency by contributing to safer care systems.
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