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 C
Explanation
Choice A Reason:
Bradycardia - Bradycardia is not a typical symptom of a haemolytic transfusion reaction.
Choice B Reason;
Hypertension - Hypertension is not a common manifestation of a haemolytic transfusion reaction.
Choice C Reason:
Back pain A haemolytic transfusion reaction is a severe and potentially life-threatening complication that can occur when the immune system reacts against the transfused red blood cells. Back pain is a classic symptom of a haemolytic transfusion reaction. It is often accompanied by other symptoms such as fever, chills, chest pain, dyspnoea, nausea, vomiting, haematuria, and hemoglobinuria (presence of haemoglobin in the urine).
Choice D Reason:
Chills - Chills can occur in various types of transfusion reactions, including haemolytic reactions, but they are not as specific as back pain for indicating a haemolytic transfusion reaction.
Correct Answer is C
Explanation
Choice A Reason:
Peripheral pulses 2+ bilaterally - This indicates good peripheral circulation and is not typically a concerning finding.
Choice B Reason:
Creatinine 0.8 mg/dL - A creatinine level of 0.8 mg/dL is within the normal range and does not indicate acute kidney failure.
Choice C Reason:
Urine specific gravity 1.045 A urine specific gravity of 1.045 is significantly elevated and could indicate concentrated urine, which might be a concern in a client with acute kidney failure. Elevated specific gravity could suggest dehydration, impaired kidney function, or other kidney-related issues. The nurse should report this finding to the provider for further evaluation and intervention.
Choice D Reason:
Weight gain 1.1 kg (2.4 lb) in 24 hr - While weight gain should be monitored closely in clients with kidney failure, 1.1 kg in 24 hours might not be an immediate concern, depending on the client's overall condition and baseline weight. However, it should still be followed up on in subsequent assessments.
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