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. Urinate after the specimen collection- Urinating after collecting the stool specimen does not affect the collection process.
B. Place 1.3 cm (0.5 in) of formed stool into a culture tube- The amount of stool needed for collection depends on the specific instructions provided, but typically, a small amount is sufficient.
C. Keep the specimen in a warm area- Stool specimens are usually kept at room temperature or refrigerated, depending on the specific requirements of the test.
D. Avoid placing toilet tissue in the bedpan after defecation- Placing toilet tissue in the bedpan can contaminate the stool specimen and affect the test results. Instructing the client to avoid doing so helps ensure the integrity of the sample.

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 B

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.

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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

A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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