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 choice 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 not recommended. Spilled solution can compromise the sterility of the field, and covering it with gauze does not restore sterility. Instead, the nurse should avoid spilling solution to maintain the sterile field.

Choice B rationale:

Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The correct technique is to hold the bottle with the label facing the palm. This prevents the label from getting wet and unreadable, ensuring that the nurse can always identify the solution correctly.

Choice C rationale:

Removing the cap and placing it sterile-side up on a clean surface is the correct action. This maintains the sterility of the cap, preventing contamination when it is replaced on the bottle. Ensuring the cap remains sterile is crucial for maintaining the sterility of 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 outside the sterile field to prevent contamination. The solution should be poured carefully to avoid splashing and compromising the sterile field.

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Correct Answer is D

Explanation

The correct answer is choice D. The nurse should determine if the client’s health care surrogate is aware of the risks and benefits of the procedure. A health care surrogate is a person who is authorized to make health care decisions for a client who is unable to do so. The nurse has a legal and ethical responsibility to ensure that the client’s surrogate has given informed consent for the surgery, which means that they have received adequate information about the procedure, its purpose, its risks, its benefits, and its alternatives.

Choice A is wrong because sending the unsigned informed consent form to the facility’s risk manager does not ensure that the client’s surrogate has given informed consent. The risk manager is not involved in the consent process and cannot authorize the surgery without the surrogate’s consent.

Choice B is wrong because ensuring that the client’s family supports the provider’s decision for surgery is not the same as obtaining informed consent from the surrogate.

The family may have different opinions or preferences than the surrogate, and the surrogate may not agree with the provider’s decision. The nurse should respect the surrogate’s autonomy and authority to make decisions for the client.

Choice C is wrong because determining if the procedure is medically necessary for the client is not the nurse’s role.

The provider is responsible for determining the medical necessity of the surgery and explaining it to the surrogate. The nurse should not question or interfere with the provider’s judgment unless there is evidence of negligence or malpractice.

A. I can lift objects that are less than 10 pounds B. I can resume activities, such as sewing C. I can go jogging after 2 weeks D. I should bend at the waist when putting on my shoes

Correct Answer is A

Explanation

The correct answer is A. I can lift objects that are less than 10 pounds.

Here's a breakdown of why the other options are incorrect:

B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.

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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?

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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