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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.
Choice B rationale:
Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.
Choice C rationale:
Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.
Choice D rationale:
Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.
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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