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.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: Placing a sterile kit on the overbed table above waist level maintains the sterility of the field. This position ensures that the kit is not contaminated by lower surfaces or inadvertent touch, which is essential for preventing infection during dressing changes.
Choice B rationale: Opening the outermost flap of the sterile kit toward their body increases the risk of contaminating the sterile field. The first flap should be opened away from the body to maintain the sterility of the field and prevent contamination.
Choice C rationale: Turning their back to the sterile field when coughing is incorrect because it increases the risk of contamination. The nurse should step away from the sterile field and cough into their elbow or use a mask to maintain sterility.
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 too high and increases the risk of contamination. The gauze should be held closer, approximately 6 inches above the field, to ensure accuracy and sterility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.
Choice B rationale:
Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.
Choice C rationale:
The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.
Choice D rationale:
Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.
Correct Answer is D
Explanation
Choice A rationale:
Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.
Choice B rationale:
Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.
Choice C rationale:
Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.
Choice D rationale:
Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.
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