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 C
Explanation
A) Add 0.5 mL of diluent to the medication. - This action is not appropriate for administering medication from an ampule since the diluent may alter the concentration and dosage of the medication.
B) Inject air into the ampule prior to drawing the medication into a syringe. - Injecting air into the ampule is unnecessary and may cause contamination.
C) Use a filter needle to aspirate the medication. - Filter needles can prevent glass particles from being drawn into the syringe when aspirating medication from an ampule.
D) Cleanse the tip of the ampule with an alcohol swab after opening. – This action is unnecessary and may contaminate the medication.
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.
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