A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

Place a sterile kit on the overbed table above waist level.

Open the outermost flap of the sterile kit toward their body.

Turn their back to the sterile field when coughing during the procedure.

Hold a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Placing a sterile kit on the overbed table above waist level is incorrect. Sterile fields need to be set up at or below waist level to ensure that they remain within the nurse's line of sight and control. This minimizes the risk of contamination and maintains the sterility of the field.

Choice B rationale:

Opening the outermost flap of the sterile kit toward their body is the correct action. This prevents air currents from blowing contaminants onto the sterile field, maintaining its sterility. Opening the flap away from the body could introduce potential contaminants onto the field, compromising its integrity.

Choice C rationale:

Turning their back to the sterile field when coughing during the procedure is incorrect. Proper aseptic technique involves turning away from the sterile field and coughing or sneezing into a tissue or elbow while maintaining a distance from the sterile area. This prevents the dispersal of microorganisms onto the field.

Choice D rationale:

Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is incorrect. The appropriate technique is to hold the gauze slightly above the sterile field to allow it to fall onto the field without direct contact. Holding it 12 inches above is unnecessary and might increase the risk of dropping it from too high, potentially contaminating the field. The height should be minimal to avoid unnecessary air currents.

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Correct Answer is B

Explanation

Choice A rationale:

The family member understanding that the nurse can adjust the mother's pain medication as needed indicates an understanding of the nurse's role in managing the patient's symptoms. However, this statement does not demonstrate an understanding of end-of-life care as a holistic process involving various aspects beyond pain management.

Choice B rationale:

This choice reflects a comprehensive understanding of end-of-life care. The family's responsibility to obtain support services shows awareness of the need for a multidisciplinary approach to address physical, emotional, and practical needs during this process. End-of-life care is a collaborative effort, and this choice accurately acknowledges the role of the family in coordinating necessary services.

Choice C rationale:

The statement about prolonging the patient's life through services reflects a misconception about end-of-life care. The focus of end-of-life care is on improving the quality of life and managing symptoms rather than attempting to extend life. This choice suggests a lack of understanding about the terminal nature of the illness.

Choice D rationale:

Believing that the doctor will make all decisions about the patient's care might indicate a lack of involvement or shared decision-making in the care process. End-of-life care often involves discussions among the medical team, patients, and their families to ensure that the patient's wishes and preferences are respected.

A. Peer pressure. B. Death of a family member. C. Fear of medical test results. D. Job transfer to another city.

Correct Answer is C

Explanation

Choice A rationale:

Peer pressure (Choice A) is an external stressor, as it involves the influence of others on an individual's thoughts or actions. It originates from outside the individual and is not directly related to an internal psychological response.

Choice B rationale:

Death of a family member (Choice B) is an external stressor, as it is an event that occurs externally to the individual. While it can cause significant emotional distress, it is not considered an internal stressor.

Choice C rationale:

Fear of medical test results (Choice C) is the correct answer as an internal stressor. Internal stressors are psychological or emotional factors that originate within the individual and contribute to stress. Fear of medical test results is a personal worry that can lead to anxiety and emotional turmoil.

Choice D rationale:

Job transfer to another city (Choice D) is an external stressor, as it involves a change in the individual's external environment. It is not an internal psychological factor causing stress.

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A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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