A nurse is caring for a 70-year-old male client on a medical-surgical unit.

Exhibits

Which action should the nurse take next?

Choice A rationale

Removing the existing dressing with sterile gloves risks contaminating the gloves and defeats the purpose of maintaining sterility throughout the procedure, increasing the likelihood of introducing pathogens to the wound.

Choice B rationale

Removing a piece of the dressing from outside the sterile field ensures adherence to sterility principles; however, contamination has already occurred if it contacts non-sterile areas, and the field must be reassessed.

Choice C rationale

Placing the existing dressing on the sterile field exposes the entire field to contaminants from the dressing, which compromises sterility and increases the potential for postoperative infections in the wound.

Choice D rationale

Restarting the procedure after sterile solution splashes onto the field ensures full sterility is maintained, as any contact with a non-sterile liquid contaminates the sterile field and increases infection risk.

Choice A rationale

Dryness is not indicative of IV infiltration as this condition involves fluid leakage into surrounding tissue, typically leading to swelling, tenderness, or other abnormal signs at the site.

Choice B rationale

Edema is a common manifestation of IV infiltration caused by fluid leaking into interstitial spaces, leading to visible and palpable swelling, which may impair IV medication delivery and compromise tissue integrity.

Choice C rationale

Erythema often indicates inflammation or phlebitis, not infiltration, as infiltration usually causes pale, cool skin due to fluid collection in surrounding tissues rather than vascular irritation.

Choice D rationale

A distended vein is associated with venous congestion or occlusion rather than infiltration. Infiltration involves fluid leakage, leading to swelling and pallor, not vein distension or increased visibility.