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 A

Explanation

Choice A reason: Client will remain free from falls throughout their hospital stay is the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is specific, measurable, attainable, realistic, and timely. This goal addresses the main risk factor for injury, which is falling, and the main outcome indicator, which is the absence of falls. This goal also reflects the client's condition, needs, and preferences, and is consistent with the standards of care and evidencebased practice.

Choice B reason: Client will increase activity tolerance by discharge from the hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

Choice C reason: Client will demonstrate effective breathing pattern when ambulating throughout hospital stay is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is irrelevant, unrelated, unnecessary, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

Choice D reason: Client will increase mobility by the time of discharge from hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

A. Call the chaplain for support B. Verify the reason for admission C. Request a medical interpreter D. Give the client a tour of the unit

Correct Answer is C

Explanation

Choice A reason: Calling the chaplain for support is not the priority nursing intervention for a client who speaks only Spanish. The chaplain may not be able to communicate with the client or understand their needs. This choice does not address the language barrier or the client's reason for admission.

Choice B reason: Verifying the reason for admission is an important nursing intervention, but it is not the priority for a client who speaks only Spanish. The nurse cannot verify the reason for admission without communicating with the client or their family. This choice does not address the language barrier or the client's safety.

Choice C reason: Requesting a medical interpreter is the priority nursing intervention for a client who speaks only Spanish. The medical interpreter can facilitate communication between the nurse and the client, and help the nurse assess the client's condition, reason for admission, and needs. This choice addresses the language barrier and the client's safety.

Choice D reason: Giving the client a tour of the unit is not the priority nursing intervention for a client who speaks only Spanish. The client may not understand the tour or the information given by the nurse. This choice does not address the language barrier or the client's reason for admission.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

Correct Answer is A

Explanation

A client arrives speaking only Spanish. What is the priority nursing intervention?

Correct Answer is C

Explanation

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