A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.)
Select a work surface at the nurse's waist level.
Open the first flap of the sterile package toward the nurse's body.
Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap.
Place & surgical pack with a sterile drape on the work surface.
Apply sterile gloves before opening the pack
Correct Answer : B,D
B. Open the first flap of the sterile package toward the nurse's body: When opening a sterile package, the nurse should open the first flap away from their body to prevent potential contamination from falling particles. This action helps maintain the sterility of the contents inside.
D. Place a surgical pack with a sterile drape on the work surface: Placing the surgical pack with a sterile drape on the work surface ensures that the sterile field is properly established. The sterile drape provides a clean and sterile area for the nurse to perform the dressing change.
Incorrect answers:
A. Select a work surface at the nurse's waist level: While it is important to select a work surface at an appropriate height for the nurse's comfort and ergonomics, the height of the work surface does not directly affect the maintenance of a sterile field.
C. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap: When opening a sterile package, the nurse should grasp the inner edge of the sterile wrap to maintain the sterility of the contents. Grasping the outer edge can potentially lead to contamination of the sterile field.
E. Apply sterile gloves before opening the pack: Sterile gloves should be applied after the sterile field is established. Opening the sterile pack and setting up the sterile field should be done with clean (non-sterile) hands to avoid contaminating the contents. Once the sterile field is set up, the nurse can don sterile gloves before actually touching the sterile items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Checking the client's vital signs is not appropriate. Checking vital signs is important to assess the severity of the reaction and monitor the client's overall condition.
Choice B reason:
Stopping the infusion is appropriate. Stopping the infusion is crucial to prevent further administration of the blood product that might be causing the adverse reaction. Once the infusion is stopped, the nurse can assess the client's condition more thoroughly and determine the appropriate steps to take next.
Choice C reason:
Collecting a urine sample is not appropriate. While urine sample collection may be important to assess for hemolysis (breakdown of red blood cells), it's not the first action to take. Stopping the infusion and assessing the client's vital signs are more immediate priorities.
Choice D reason:
Administering oxygen to the client is not appropriate. Providing oxygen might be necessary if the client is experiencing respiratory distress, but it's not the first action to take. Stopping the infusion and assessing the situation before providing additional interventions.
Correct Answer is B
Explanation
Choice A Reason:
Placing the client in a protective environment is not necessary for C. difficile gastroenteritis. Standard precautions, including diligent hand hygiene and appropriate personal protective equipment, are sufficient.
Choice B Reason:
Obtain a stool specimen with gloves is necessary. Obtaining a stool specimen with gloves is an appropriate nursing action when caring for a client with Clostridium difficile (C. difficile) gastroenteritis. C. difficile is a bacterium that can cause diarrhea and other gastrointestinal symptoms. It's important to follow infection control practices to prevent the spread of the bacteria.
Choice C Reason:
Cleaning surfaces with chlorhexidine is not the preferred disinfectant for C. difficile. Sporicidal agents, such as bleach-based solutions, are recommended to effectively kill the spores of C. difficile.
Choice D Reason:
Washing hands with alcohol-based hand rub is not sufficient for C. difficile. C. difficile spores are resistant to alcohol-based hand sanitizers, so using soap and water for handwashing is recommended to ensure proper removal of the spores.
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