To accurately take a client's blood pressure, which action by the nurse is most important?

Choice A rationale:

The anterior surface of the drape is not the correct choice because it includes the central sterile area, which should never be touched by the nurse. Touching the central sterile area contaminates the field.

Choice B rationale:

The outer 1-inch border of the drape is the correct choice for the nurse to touch. This border is considered non-sterile and can be handled without contaminating the sterile field. It acts as a barrier, preventing contaminants from reaching the central sterile area.

Choice C rationale:

The top inner corners of the drape are part of the central sterile area and should not be touched by the nurse. Touching this area would contaminate the sterile field.

Choice D rationale:

The posterior aspect of the drape is not the correct choice because it is part of the central sterile area. Touching this area would contaminate the sterile field. When preparing a sterile field, it is essential for the nurse to follow strict aseptic techniques to maintain the sterility of the field. This includes touching only the designated non-sterile areas, such as the outer 1-inch border of the sterile drape, to avoid contamination.

Choice A rationale:

Standard precautions, as established by the Center for Disease Control (CDC), are to be used for any client, regardless of whether an infection has been identified. This means that healthcare providers, including nurses, must apply standard precautions in the care of all patients to prevent the spread of infections. The rationale behind this choice is based on the fundamental principle of infection control: it is not always possible to identify patients who may be carrying harmful pathogens. Some patients may not show visible signs of infection or may be in the incubation period of a disease, during which they are contagious but not symptomatic. Therefore, applying standard precautions universally helps to create a safe healthcare environment for both patients and healthcare providers. Standard precautions include practices such as hand hygiene, the use of personal protective equipment (PPE) like gloves and masks, safe injection practices, and respiratory hygiene.

Choice B rationale:

This choice incorrectly specifies the mode of transmission for using standard precautions. Standard precautions are not limited to cases where the infection is transmitted on air currents. Airborne precautions are used for diseases that spread via small droplets in the air, such as tuberculosis and measles. Standard precautions, on the other hand, cover a broader range of infections and are applied to all patients.

Choice C rationale:

This choice incorrectly narrows down the usage of standard precautions to cases where the infection spreads via moist droplets. While it is true that standard precautions include measures to prevent the transmission of infections through respiratory droplets, they are not limited to this mode of transmission. Standard precautions encompass various modes of transmission, including contact with blood and other body fluids, as well as contact with contaminated surfaces or items.

Choice D rationale:

This choice wrongly states that standard precautions are only used when there is an infection spread by indirect contact with an organism. Standard precautions include both direct and indirect contact with patients and their environment. It is not limited to specific types of infections or modes of transmission.