A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?

Place sterile gauze over areas of spilled solution within the sterile field.

Hold the irrigation solution bottle with the label facing away from the palm of the hand.

Remove the cap and place it sterile-side up on a clean surface.

Hold the bottle in the center of the sterile field when pouring the solution.

Answer and Explanation

The Correct Answer is C

The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.

Choice A rationale:

Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution

Choice D rationale:

Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills

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Correct Answer is B

Explanation

The correct answer is choice b. Using an electronic messaging system to remind clients when to take medications.

Choice A rationale:

Educating clients about contraindications to specific immunizations is an example of primary prevention, which aims to prevent disease before it occurs.

Choice B rationale:

Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention. It helps manage an existing condition (HIV) by ensuring adherence to treatment, thereby preventing complications and improving quality of life.

Choice C rationale:

Providing clients with information about the benefits of exercise is generally considered primary prevention, as it aims to promote overall health and prevent disease.

Choice D rationale:

Helping clients understand health screenings covered by their insurance plans is an example of secondary prevention, which focuses on early detection and treatment of disease.

A. A butterfly needle. B. An angiocatheter. C. A 25-gauge needle. D. A noncoring needle.

Correct Answer is D

Explanation

A noncoring needle is a special type of needle that has a beveled tip and a side hole. It is designed to prevent damage to the port’s septum, which is the soft silicone top that serves as the vein access point. A noncoring needle also reduces the risk of infection and clotting.

Choice A is wrong because a butterfly needle is a small, winged needle that is used for peripheral venous access, not for accessing a port. A butterfly needle can damage the port’s septum and cause leakage or infection.

Choice B is wrong because an angiocatheter is a thin, plastic tube that is inserted into a vein using a needle.

It is used for short-term IV therapy, not for accessing a port. An angiocatheter can also damage the port’s septum and cause complications.

Choice C is wrong because a 25-gauge needle is too small to access a port.

A 25-gauge needle is typically used for subcutaneous injections, not for intravenous injections. A 25-gauge needle can also clog the port or cause hemolysis (breakdown of red blood cells).

Normal ranges for ports vary depending on the type and size of the port, but generally they have a reservoir diameter of 1.5 to 2.5 cm, a catheter length of 40 to 60 cm, and a catheter diameter of 0.8 to 1.2 mm. Ports are usually flushed with saline or heparin solution every 4 to 6 weeks when not in use to prevent clotting.

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A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?

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A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?