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:
Changing the catheter dressing daily - While it's important to maintain the dressing and keep it clean and dry, changing the dressing daily might not be necessary. The dressing should be changed according to facility policy and based on assessment findings.
Choice B Reason:
Cleaning the insertion site using 20 mL of hydrogen peroxide - Hydrogen peroxide is not recommended for cleaning PICC line insertion sites, as it can cause tissue irritation. The insertion site should be cleaned with an appropriate antiseptic solution per facility guidelines.
Choice C Reason:
Use a 10-mL syringe to flush the line. When completing discharge teaching for a client with a peripherally inserted central catheter (PICC) line, the nurse should include instructions regarding the proper care of the line. Using a 10-mL syringe to flush the line is the appropriate practice to prevent excessive pressure within the catheter and minimize the risk of catheter damage or rupture.
Choice D Reason:
Not elevating the arm above the level of the heart - Elevation of the arm above the heart level is generally not contraindicated for a PICC line. However, it's important to avoid activities that could lead to kinking or pulling on the line. The nurse should provide specific instructions regarding arm movement and care to the client.
Correct Answer is A
Explanation
Placing the client in high-Fowler's position is the appropriate action. When administering peritoneal dialysis, the nurse should place the client in a high-Fowler's position. This position helps promote the flow of dialysate into and out of the peritoneal cavity and assists with proper drainage. The high-Fowler's position allows for gravity to aid in the movement of fluid and helps prevent leakage of fluid back into the catheter.
Choice B Reason:
Chilling the dialysate before administration is not necessary and could cause discomfort to the client. Dialysate should be warmed to body temperature before use.
Choice C Reason:
Hanging the drainage bag below the client's abdomen is incorrect. The drainage bag should be positioned below the level of the abdomen to allow for proper drainage by gravity, but it should not be hung too low as this can lead to excessive drainage and dehydration.
Choice D Reason:
Using clean technique to access the catheter is incorrect. Sterile technique is required when accessing the peritoneal dialysis catheter to prevent infection. Peritoneal dialysis involves direct access to the peritoneal cavity, which is considered a sterile body cavity.
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