A nurse is teaching a client about skin cancer prevention. Which of the following statements by the client indicates an understanding of the teaching?

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.

Rationale:

A. Set up the sterile field 5 cm (2 in) below waist level: Sterile fields must be at or above waist level to maintain sterility. Anything below the waist is considered contaminated because it is out of the nurse’s visual field and control.

B. Place the cap from the solution sterile side up on a clean surface: The inside of the cap must face up to avoid contamination. Placing it on a clean surface with the sterile side up preserves sterility for recapping the solution if needed.

C. Open the outermost flap of the sterile kit toward the body: The first flap should be opened away from the body to prevent reaching over the sterile field, which increases the risk of contamination.

D. Place the sterile dressing within 1.25 cm (0.5 in) of the ledge of the sterile field: Items must be placed at least 2.5 cm (1 in) from the edge of the sterile field. The outer 1 inch is considered non-sterile and any item placed within this margin is no longer sterile.