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 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.

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Correct Answer is B

Explanation

Choice A rationale:

Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.

Choice B rationale:

Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.

Choice C rationale:

Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.

Choice D rationale:

Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.

A. Perform oral care once each day. B. Brush the client's teeth with a firm-bristle toothbrush. C. Swab the client's mouth with chlorhexidine solution. D. Raise the head of the bed 15° for oral care.

Correct Answer is C

Explanation

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.

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