A break in the sterile field occurs when the nurse does which of the following? (Select all that apply)

Spills sterile saline solution onto the sterile field

Drops a sterile capped needle onto the sterile field

The table remains above waist level during the procedure

The nurse lowers a gloved hand below the waist

The culture swab touches the drape’s 1-inch border

Answer and Explanation

Correct Answer : A,D,E

Choice A reason: Spilling sterile saline onto the sterile field introduces potential contaminants, as the liquid may carry microbes from surrounding areas, compromising sterility. This breaks the sterile field, making it correct.

Choice B reason: Dropping a sterile capped needle onto the sterile field does not introduce contaminants, as the needle remains sterile. The field remains intact, making this an incorrect choice for a break.

Choice C reason: Keeping the table above waist level maintains sterility, as areas below the waist are considered contaminated. This is a correct practice, not a break, making it incorrect.

Choice D reason: Lowering a gloved hand below the waist exposes it to non-sterile areas, contaminating the glove. This compromises the sterile field when the hand returns, making it a correct choice.

Choice E reason: The drape’s 1-inch border is considered non-sterile. A culture swab touching it becomes contaminated, breaking the sterile field when reintroduced, making this a correct choice.

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Correct Answer is C

Explanation

Choice A reason: Pain relieved by eating is not typical of appendicitis, which often worsens with food intake due to inflammation. This suggests a gastrointestinal issue like gastritis, making it incorrect for appendicitis.

Choice B reason: Pain radiating to the back is more associated with conditions like pancreatitis or aortic aneurysm. Appendicitis pain is localized or radiates to the right lower quadrant, making this incorrect.

Choice C reason: Pain at McBurney’s point (right lower quadrant, midway between umbilicus and iliac crest) is a classic appendicitis sign due to localized inflammation. This specificity makes it the correct finding.

Choice D reason: Pain worsened by deep breathing may occur in pleuritic or abdominal conditions but is not specific to appendicitis. McBurney’s point pain is more diagnostic, making this less indicative.

A. Stress that older patients usually ask for help when needed B. Inform the family that placement in a nursing center is a permanent solution C. Provide information and answer questions as the patient and staff members make choices among care options D. Tell the family to enroll the patient in a ceramics class to maintain quality of life

Correct Answer is C

Explanation

Choice A reason: Stating that older patients usually ask for help is inaccurate, as some may avoid requesting assistance due to pride or unawareness. Providing information empowers informed decisions, promoting independence more effectively than relying on assumptions about help-seeking behavior.

Choice B reason: Suggesting permanent nursing home placement dismisses rehabilitation potential. Providing information about care options supports tailored plans for independence, as many patients can regain self-care abilities with therapy, making this choice incorrect.

Choice C reason: Providing information and answering questions empowers the patient and family to choose care options (e.g., therapy, aids) that promote independence. This collaborative approach fosters self-care by aligning interventions with the patient’s goals, making it the most effective action.

Choice D reason: Enrolling in a ceramics class may enhance quality of life but does not directly address mobility or self-care post-hip fracture. Education on care options better supports functional recovery, making this choice less relevant to promoting independence.

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A break in the sterile field occurs when the nurse does which of the following? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports abdominal pain. Which of the following findings should the nurse identify as a possible indication of appendicitis?

Correct Answer is C

Explanation

The nurse is educating the family of a patient with limited mobility after a hip fracture. Which action should the nurse take to help promote independence and self-care?

Correct Answer is C

Explanation

In which patient will the nurse expect to see a positive Chvostek sign?

Which statement made by the patient is an indication for the nurse to use the Z-track method?

Which patient will the nurse see first?

Which of the following clients is most appropriate to delegate to the Licensed Practical/Vocational Nurse (LPN/LVN)?

Which patient is most at risk for developing an infection?

A nurse is teaching a client who has a new prescription for warfarin about medication interactions. Which of the following medications should the nurse instruct the client to avoid?

The nurse is caring for an 84-year-old patient. Which finding would be expected?

A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?