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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

WBC count 8,400/mm3 is not appropriate. This white blood cell count is within the normal range and is not a cause for concern.

Choice B reason:

Serosanguineous exudate noted on dressing change is not appropriate. Serosanguineous drainage is a normal finding in the early stages of wound healing and is expected after surgery.

Choice C reason:

Reports pain of 4 on a scale from 0 to 10 when coughing is not appropriate. A pain level of 4 out of 10 with coughing is a common and expected finding following an appendectomy. It's important for the nurse to assess and manage pain, but this is not an urgent concern.

Choice D reason:

Haemoglobin 10 mg/dL is appropriate. Haemoglobin level of 10 mg/dL indicates a low level of haemoglobin, which might suggest anaemia or blood loss. Reporting this finding to the provider is important as it could indicate a need for further evaluation or intervention.

A. Calcium level 11,5 mg/dl B. Serum albumin level 3.9 g/dL C. Output 200 ml, more than intake over the past 12 hr. D. Fasting blood glucose level 105 mg/dL

Correct Answer is A

Explanation

Choice A reason:

A calcium level of 11.5 mg/dL is elevated. Normal calcium levels typically range from 8.5 to 10.5 mg/dL. Hypercalcemia can lead to various complications, including cardiac arrhythmias and neurological symptoms. The nurse should notify the provider of this finding for further evaluation and management.

Choice B reason

Serum albumin level 3.9 g/dL is not appropriate. This level is within a reasonable range for serum albumin. It might be an indicator of nutritional status, but it's not an urgent concern.

Choice C reason:

Output exceeding intake over a 12-hour period may indicate fluid imbalance or inadequate intake compared to output. However, without further context, such as the client's overall fluid status, this finding alone may not be alarming. The nurse should assess the client's hydration status, consider potential causes of increased output, and address any concerns accordingly. While the nurse may need to monitor closely and address any potential issues, immediate notification of the provider may not be necessary based solely on this finding.

Choice D reason:

Fasting blood glucose level 105 mg/dL is not appropriate: A fasting blood glucose level of 105 mg/dL is slightly elevated, but it's not a critically high value. The nurse should monitor blood glucose levels and collaborate with the healthcare team to manage blood glucose appropriately.

However, if the client has a history of diabetes or if there are other concerning factors, such as consistent high glucose levels or symptoms of hyperglycemia, the nurse may need to monitor closely and notify the provider for further evaluation and management. Otherwise, this finding alone may not warrant immediate notification.

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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.)

Nursing Test Bank

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