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 {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
The correct answer is Constipation / Opioid use.
Constipation is a common side effect of opioid use. The client is receiving oxycodone for pain management, which can slow down the digestive system, leading to constipation.
Pressure injuries, also known as pressure ulcers or bedsores, are a risk due to prolonged immobility. This is especially relevant for a client who is postoperative and has limited movement. However, this was not selected as the primary condition based on the given clues.
Hypoglycemia (low blood sugar) is not directly indicated by the client's current medications or conditions. The client is receiving IV dextrose, but there is no indication of a risk of hypoglycemia in the provided information.
Confusion can occur in clients with cognitive impairments or due to medication side effects, but it is not specifically indicated as a primary risk in this case.
Dysrhythmias (abnormal heart rhythms) can be caused by imbalances in potassium or sodium levels, among other factors, but there is no evidence of such imbalances or related symptoms in this client’s case.
Correct Answer is A
Explanation
Choice A rationale
Keeping elbows slightly bent when grasping the walker helps to maintain stability and control. This positioning reduces the strain on the arms and shoulders, providing a more comfortable and effective way to use the walker.
Choice B rationale
Sliding the walker and moving it about a foot in front can cause instability. Instead, lifting the walker and placing it step-by-step ensures better support and reduces the risk of falls.
Choice C rationale
Moving the walker and the stronger leg at the same time can lead to imbalance and falls. The correct method is to move the walker first, then step forward with the weaker leg, followed by the stronger leg.
Choice D rationale
Keeping the walker height adjusted so the user leans slightly forward is incorrect. The walker height should be at the level of the wrists when the arms are hanging down, allowing for a natural and upright posture.
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