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). .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Health information should not be disclosed to an employer for pre-employment screening without the client's consent, as it violates privacy regulations and the client's right to confidentiality. Such disclosures could lead to discrimination or bias in employment decisions.
Choice B rationale
Disclosing health information to a family member without the client's consent is a breach of confidentiality. The client must provide explicit permission, unless the situation involves an immediate risk to the client's or others' safety, which is not indicated here.
Choice C rationale
Sharing health information with a medical interpreter service on behalf of a client is permissible, as it facilitates communication between the client and healthcare providers. This action supports the client's care and ensures accurate understanding of medical information, making it an exception to the confidentiality rule.
Choice D rationale
Disclosing health information to an insurance agency regarding a life insurance policy requires the client's consent. It involves sharing sensitive information that could affect policy terms and premiums. Without consent, this disclosure would breach confidentiality laws.
Correct Answer is A,B,C,D,E
Explanation
A. Apply clean gloves.
B. Disconnect the tube from the suction device.
C. Instill 50 mL of air into the tube.
D. Ask the client to take a deep breath.
E. Pinch and withdraw the tube.
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