A 49-year-old female patient receives 3% NaCl solution for the correction of hyponatremia. Which assessment is most important for the nurse to monitor while the patient is receiving this infusion?

Choice A: All materials that enter the sterile field must be sterile

This is a correct principle of aseptic technique. Ensuring that all materials entering the sterile field are sterile is fundamental to preventing contamination and infection during surgical procedures. Any non-sterile item introduced into the sterile field can introduce pathogens, compromising patient safety.

Choice B: The surgical team working in the operative field must wear sterile gowns and gloves

This is another correct principle. Members of the surgical team who work directly in the operative field must wear sterile gowns and gloves to create a barrier against microorganisms. This practice helps maintain the sterility of the surgical environment and protects both the patient and the healthcare providers.

Choice C: The sterile package is contaminated once it has been opened

This statement is incorrect. A sterile package is not necessarily contaminated once it has been opened, provided it is opened correctly and the contents are handled using aseptic techniques. Proper opening and handling ensure that the sterility of the contents is maintained.

Choice D: The circulating nurse must wear sterile gowns and gloves

This statement is incorrect. The circulating nurse does not need to wear sterile gowns and gloves because they do not work directly in the sterile field. Instead, they assist by providing necessary supplies and support from outside the sterile area.

Choice E: Tables are sterile only at tabletop level. Items extending beneath this level are contaminated

This is a correct principle. In the operating room, the sterility of tables is maintained only at the tabletop level. Any items that extend below this level are considered contaminated and should not be used in the sterile field.

Choice F: A wide margin of safety is maintained between sterile and unsterile fields

This is also a correct principle. Maintaining a wide margin of safety between sterile and unsterile fields helps prevent accidental contamination. This practice ensures that sterile areas remain uncontaminated by non-sterile items or personnel.

Choice A: Agency policy

While agency policy provides guidelines for reassessment intervals, it is not the primary factor in determining the specific time frame for reassessing a patient’s pain level. Policies serve as a general framework, but individual patient needs and clinical judgment should guide the reassessment timing.

Choice B: Type of intervention

This is a correct answer. The type of pain management intervention used significantly influences the reassessment time frame. For example, after administering intravenous pain medication, reassessment should occur sooner compared to oral medications due to the faster onset of action. Different interventions have varying durations of effectiveness, necessitating tailored reassessment intervals.

Choice C: Pain severity

This is another correct answer. The severity of the patient’s pain is a crucial factor in determining reassessment timing. Patients experiencing severe pain may require more frequent reassessments to ensure that pain management strategies are effective and to make timely adjustments if needed.

Choice D: If family members are present in the patient’s room

The presence of family members in the patient’s room is not a primary factor in determining the reassessment time frame. While family members can provide valuable support and information, the focus should remain on the patient’s clinical needs and the effectiveness of pain management interventions.

Choice E: The patient’s psychosocial condition

This is a correct answer. The patient’s psychosocial condition, including their emotional and mental state, can impact their perception of pain and response to pain management. Patients with anxiety, depression, or other psychosocial issues may require more frequent reassessments to address both physical and emotional aspects of pain.

Choice F: Risks for adverse effects

This is also a correct answer. The potential for adverse effects from pain management interventions necessitates careful monitoring and timely reassessment. For instance, opioids carry risks of respiratory depression and sedation, requiring close observation and frequent reassessment to ensure patient safety.

Choice G: Workload of the nurse

While the nurse’s workload can influence the practical aspects of care delivery, it should not dictate the reassessment time frame. Patient needs and clinical priorities should guide reassessment intervals, with workload management being a secondary consideration.

Choice H: The patient’s physical condition

This is the final correct answer. The patient’s overall physical condition, including comorbidities and current health status, affects their response to pain management and the need for reassessment. Patients with complex medical conditions may require more frequent monitoring to ensure effective pain control and to promptly address any complications.