What steps are included in preparing a sterile field? (Select all that apply.)

Obtain a PAPR mask

Do not turn away from the sterile field

Add items to the sterile field by dropping them gently

Cover the sterile field once it is set up

Prepare the client before setting up the sterile field

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Obtaining a PAPR mask is not a step in preparing a sterile field. A PAPR mask is a powered airpurifying respirator that protects the wearer from airborne contaminants. It is not required for setting up a sterile field, unless the client has a highly infectious disease.

Choice B reason: Do not turn away from the sterile field is a step in preparing a sterile field. Turning away from the sterile field can contaminate the field or the items on it. The nurse should always face the sterile field and keep it in view.

Choice C reason: Add items to the sterile field by dropping them gently is a step in preparing a sterile field. Dropping items gently onto the sterile field prevents splashing or touching the field or the items. The nurse should open the sterile packages away from the field and drop the items close to the edge of the field.

Choice D reason: Covering the sterile field once it is set up is not a step in preparing a sterile field. Covering the sterile field can compromise its sterility and create moisture that can harbor microorganisms. The nurse should not cover the sterile field unless it is necessary to move it or store it for later use.

Choice E reason: Preparing the client before setting up the sterile field is a step in preparing a sterile field. Preparing the client involves explaining the procedure, obtaining consent, providing privacy, and positioning the client. The nurse should prepare the client before setting up the sterile field to avoid leaving the field unattended or exposing it to the client's body fluids.

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Correct Answer is C

Explanation

Choice A reason: Deeply palpating the area for rebound tenderness is not the nurse's next action, because it is inappropriate and dangerous. Deeply palpating the area for rebound tenderness is a test that involves applying and releasing pressure on the abdomen, which can elicit pain or discomfort in the presence of peritonitis or appendicitis. Deeply palpating the area for rebound tenderness is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Deeply palpating the area for rebound tenderness can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice B reason: Percussing over the area for a change in tone is not the nurse's next action, because it is inappropriate and useless. Percussing over the area for a change in tone is a test that involves tapping on the chest or abdomen, which can produce different sounds depending on the density of the underlying organs or tissues. Percussing over the area for a change in tone is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Percussing over the area for a change in tone can also worsen the pain, damage the tissues, or dislodge the clot, which can cause pulmonary embolism, which is a lifethreatening condition.

Choice C reason: Comparing the circumference to the left calf is the nurse's next action, because it is appropriate and useful. Comparing the circumference to the left calf is a test that involves measuring the size of the leg, which can reveal any swelling or edema in the affected area. Comparing the circumference to the left calf is relevant and useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Comparing the circumference to the left calf can also help diagnose, monitor, or treat the condition, as a difference of more than 2 cm between the legs can suggest a DVT.

Choice D reason: Medicating the client for pain and reassessing in 60 minutes is not the nurse's next action, because it is inappropriate and delayed. Medicating the client for pain and reassessing in 60 minutes is an intervention that involves giving the client a painkiller and checking the response after an hour. Medicating the client for pain and reassessing in 60 minutes is not relevant or useful for the client's complaint of pain and burning in the right calf area, which may indicate a deep vein thrombosis (DVT), which is a blood clot in the deep veins of the leg. Medicating the client for pain and reassessing in 60 minutes can also mask the symptoms, delay the diagnosis, or miss the opportunity to prevent the complications, such as pulmonary embolism, which is a lifethreatening condition.

A. Creating a susceptible host B. Maintaining the integrity of a portal of entry C. Creating a reservoir to decrease the risk of infection D. Sterilizing the area to reduce the reservoir risk

Correct Answer is B

Explanation

Choice A reason: Creating a susceptible host is not a way to break the chain of infection, but rather a way to facilitate it. A susceptible host is someone who is vulnerable to infection due to factors such as age, immunocompromised status, or chronic diseases.

Choice B reason: Maintaining the integrity of a portal of entry is a way to break the chain of infection, because it prevents the entry of microorganisms into the body. A portal of entry is any place where microorganisms can enter the body, such as the skin, mucous membranes, or respiratory tract. By reducing skin breakdown, the nurse is protecting the skin from becoming a portal of entry for infection.

Choice C reason: Creating a reservoir to decrease the risk of infection is a contradiction, because a reservoir is a place where microorganisms can multiply and survive, such as a human, animal, or environment. A reservoir increases the risk of infection, not decreases it.

Choice D reason: Sterilizing the area to reduce the reservoir risk is a way to break the chain of infection, but it is not related to reducing skin breakdown. Sterilizing the area means killing or removing all microorganisms from a surface or object, such as a surgical instrument or a wound dressing. This can reduce the reservoir risk, but it does not affect the integrity of the skin as a portal of entry.

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What steps are included in preparing a sterile field? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A client on bedrest complains of pain and burning in the right calf area. What is the nurse's next action?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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