A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
Opening the top flap of the sterile tray package away from their body
Dropping sterile objects onto the field from a height of 5 cm (2 in)
Placing the cap of a sterile solution on a clean surface with the inside facing down
The Correct Answer is B
A) Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field - Sterile items should be kept within the confines of the sterile field to maintain sterility.
B) Opening the top flap of the sterile tray package away from their body - Opening the sterile package away from the body helps prevent contamination from airborne particles or droplets.
C) Dropping sterile objects onto the field from a height of 5 cm (2 in) - Dropping sterile objects can create air currents that may introduce contamination to the sterile field, for instance, through splashing.
D) Placing the cap of a sterile solution on a clean surface with the inside facing down
- Sterile items should be handled with care to maintain sterility, and placing the cap with the inside facing down may introduce contamination. The inside of the cap should face up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A) Observe the client's skin integrity every 2 hr. - Regular skin assessments are essential to monitor for any signs of skin breakdown or injury related to the use of restraints.
B) Use a square knot to secure the client's restraint to the bed. - A quick-release knot, not a square knot, should be used to secure restraints for easy removal in case of an emergency.
C) Ensure that 2 fingers can be placed between the restraint and the client. - This ensures that the restraint is not too tight, allowing for circulation and preventing injury.
D) Tie the ends of the restraint to the client's bed rail. - Restraints should not be tied to the bed rail as it can increase the risk of injury and entrapment.
E) Pad bony prominences before applying a restraint. - Padding bony prominences helps prevent pressure injuries and discomfort for the client.
Correct Answer is B
Explanation
A) Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B) Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C) Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D) Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.
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