A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take?

Pour liquid by holding the bottle with the label facing the sterile field.

Prepare the sterile field 5 cm (2 in) below the level of the waist.

Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field.

Open the outermost flap of the wrapper toward the body.

Answer and Explanation

The Correct Answer is C

A. Pour liquid by holding the bottle with the label facing the sterile field: When pouring solutions onto a sterile field, the label should face the nurse’s hand, not the sterile field. This prevents the liquid from running down the bottle and obscuring or washing off the label, which maintains accurate identification of the solution while protecting the sterile field.

B. Prepare the sterile field 5 cm (2 in) below the level of the waist: The sterile field should be set up at or above waist level to prevent accidental contamination. Positioning it below waist level increases the risk of droplets, contact with nonsterile surfaces, or accidental touches, compromising sterility.

C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field: Maintaining this distance ensures that the fluid is poured without splashing or touching the sterile field with the bottle, which reduces contamination risk. This technique balances control and safety while preserving sterility during preparation or dressing changes.

D. Open the outermost flap of the wrapper toward the body: The outermost flap should be opened away from the body to prevent reaching over the sterile field, which could result in accidental contamination. Opening toward the body increases the chance that clothing or hands might contact the sterile surface.

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Correct Answer is C

Explanation

A. Pull the auricle upward and outward: While pulling the auricle upward helps straighten the external auditory canal in adults, directing it outward does not fully align the canal’s natural S-shaped curve. Proper straightening requires a backward motion to allow the medication to flow toward the tympanic membrane effectively.

B. Pull the auricle downward and backward: Pulling the auricle downward and backward is the technique used for children younger than 3 years of age. In young children, the ear canal is more horizontal, and this maneuver helps straighten it appropriately. This method is not correct for adults.

C. Pull the auricle upward and backward: In adults, the external auditory canal curves upward and posteriorly. Pulling the auricle upward and backward straightens the canal, facilitating proper instillation of the medication and ensuring it reaches the intended area near the tympanic membrane.

D. Pull the auricle downward and outward: This technique does not effectively straighten the adult ear canal. Incorrect positioning can result in medication pooling in the outer canal rather than reaching the deeper structures where therapeutic action is needed.

A. Provide a tour of the perioperative area prior to surgery. B. Explain that anesthesia is a special type of sleep. C. Wait until after surgery to explain the importance of coughing and deep breathing. D. Keep medical equipment out of the client's sight.

Correct Answer is A

Explanation

A. Provide a tour of the perioperative area prior to surgery: Familiarizing an adolescent with the surgical environment helps reduce anxiety, promotes understanding of the procedure, and encourages cooperation. A tour allows the client to see equipment, meet staff, and ask questions, which supports emotional preparation and informed consent.

B. Explain that anesthesia is a special type of sleep: Describing anesthesia as “sleep” can be misleading and may cause fear or misunderstanding about the procedure. Adolescents benefit from honest, age-appropriate explanations about anesthesia, including how it works and safety measures, rather than oversimplified analogies.

C. Wait until after surgery to explain the importance of coughing and deep breathing: Preoperative teaching about postoperative exercises, including coughing and deep breathing, helps prevent complications such as atelectasis and pneumonia. Delaying instruction reduces the client’s readiness and may decrease adherence after surgery.

D. Keep medical equipment out of the client's sight: While minimizing exposure to intimidating equipment can reduce anxiety for younger children, adolescents are generally better able to process information. Hiding equipment can increase fear of the unknown, whereas exposure during a tour helps normalize the environment and improve coping.

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