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. Hypocalcemia- Vomiting and diarrhea can lead to fluid and electrolyte losses, but hypocalcemia is not a common finding in this scenario.
B. Hypermagnesemia- Hypermagnesemia is unlikely in the context of vomiting and diarrhea, as these conditions typically result in magnesium loss.
C. Hyperkalemia- Vomiting and diarrhea can lead to potassium loss, making hyperkalemia less likely.
D. Hypokalemia- Vomiting and diarrhea can cause potassium depletion, leading to hypokalemia. This electrolyte imbalance is commonly seen in clients with gastrointestinal losses.

A. Administer a sedative medication to the client. B. Have the client sign an against medical advice form. C. Tell the client that the surgeon will prescribe restraints if they try to leave. D. Explain to the client that they cannot leave until the surgeon discharges them.

Correct Answer is D

Explanation

A. Administer a sedative medication to the client- Administering a sedative medication without proper indication and consent is not appropriate in this situation.
B. Have the client sign an against medical advice form- Having the client sign an against medical advice (AMA) form is premature and should only be considered after thorough discussion of the risks and benefits of leaving against medical advice.
C. Tell the client that the surgeon will prescribe restraints if they try to leave- Threatening the client with restraints is coercive and not conducive to a therapeutic nurse-client relationship. Restraints should only be used as a last resort to ensure safety.
D. Explain to the client that they cannot leave until the surgeon discharges them- The nurse should explain to the client that leaving before being discharged by the surgeon can jeopardize their recovery and may result in complications. It is important to communicate the consequences of leaving prematurely and encourage the client to wait for proper discharge instructions.

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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