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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Return the medication to the medication cabinet- Returning the medication without addressing the client's concerns does not promote understanding or collaboration.
B. Notify the provider of the client's refusal- Notifying the provider is important but should come after attempting to address the client's concerns.
C. Document the refusal in the client's medical record- Documentation is necessary but should follow a discussion with the client.
D. Inform the client of the potential consequences of their refusal- The nurse should first educate the client about the risks associated with not taking their antihypertensive medication to ensure they are making an informed decision.

A. Obtain urine from the drainage bag if a urinary specimen is required. B. Use a catheter securing device to hold the catheter in place. C. Change the catheter bag every 3 days and as needed. D. Position the drainage bag higher than the client's bladder.

Correct Answer is B

Explanation

A. Obtain urine from the drainage bag if a urinary specimen is required- Urine specimens should be collected from the catheter port using a sterile technique, not from the drainage bag.
B. Use a catheter securing device to hold the catheter in place- A catheter securing device helps prevent movement or accidental removal of the catheter, reducing the risk of trauma or dislodgment.
C. Change the catheter bag every 3 days and as needed- Catheter bags should be changed according to facility policy or if they become soiled, not necessarily every 3 days.
D. Position the drainage bag higher than the client's bladder- The drainage bag should be positioned lower than the client's bladder to facilitate urine drainage by gravity and prevent reflux into the bladder.

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A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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