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

Placing the cap of a sterile solution on a clean surface with the inside facing down.

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). .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Placing the cap of a sterile solution on a clean surface with the inside facing down can contaminate the cap. It should be placed with the inside facing up to maintain sterility.

Choice B rationale

Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field risks contamination, as the edges are considered non-sterile. Instruments should be placed well within the sterile field.

Choice C rationale

Opening the top flap of the sterile tray package away from their body ensures that the sterile contents are not contaminated by the nurse's clothing or body, maintaining the sterility of the field.

Choice D rationale

Dropping sterile objects onto the field from a height of 5 cm (2 in) can cause contamination due to the potential for the objects to fall outside the sterile field. Objects should be placed gently onto the field without dropping them.

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Correct Answer is C

Explanation

Choice A rationale

A small amount of liquid stool draining from the stoma is expected during the early postoperative period following colostomy placement. This indicates that the stoma is functioning and passing waste as intended.

Choice B rationale

The stoma protruding slightly from the abdomen, known as stoma protrusion or eversion, is a common and normal finding. It indicates that the stoma is correctly positioned and healing properly.

Choice C rationale

A dark-colored stoma is a concerning sign that indicates compromised blood flow to the stoma tissue, potentially leading to necrosis. This requires immediate medical attention to address the underlying cause and prevent further complications.

Choice D rationale

Light bleeding from the stoma when touched is normal in the immediate postoperative period. The stoma tissue is highly vascular, and minor bleeding is expected as it heals and forms new tissue connections.

A. Check the client's medical records to see which medications were recently administered. B. Review the client's most recent SaO2 level in the medical record. C. Notify the charge nurse of the client's condition. D. Recheck the client's SaO2 level after having the client cough and clear their throat.

Correct Answer is D

Explanation

Choice A rationale

While checking recent medication administration is important, it is not the immediate priority when a client is experiencing shortness of breath. Immediate actions should focus on assessing and improving the client's oxygenation status.

Choice B rationale

Reviewing the client’s most recent SaO2 level is useful, but not the first action to take when there is an immediate concern for the client’s oxygenation. Addressing the current low SaO2 level takes precedence.

Choice C rationale

Notifying the charge nurse is necessary, but the nurse should first attempt to quickly re-evaluate the client’s condition and try simple interventions to improve oxygenation, such as having the client cough and clear their throat.

Choice D rationale

Rechecking the SaO2 level after having the client cough and clear their throat is the appropriate first action. This can help determine if the low SaO2 reading is due to a temporary obstruction, such as mucus, and allows for a more accurate assessment of the client's respiratory status. .

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