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
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.
Choice B rationale
Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.
Choice C rationale
Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.
Choice D rationale
Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.
Correct Answer is A
Explanation
Choice A rationale
Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.
Choice B rationale
Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.
Choice C rationale
Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.
Choice D rationale
Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.
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