A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
The sterile solution is poured with the bottle held over the field.
Unnecessary sterile items are placed on the field.
The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
The Correct Answer is B
Rationale:
A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.
B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.
C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.
D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Avoiding the use of facial gestures during the instructions may not be effective for a client with expressive aphasia.
B. Determining the client's ability to use a communication board is appropriate because it helps the nurse understand how the client communicates.
C. Speaking with a loud voice while providing the information may not be effective for a client with expressive aphasia.
D. Providing the teaching without expecting the client to respond may not be effective for a client with expressive aphasia.
Correct Answer is B
Explanation
A. Cleaning around the stoma with a moisturizing soap is not recommended. Moisturizing soaps can leave a residue that may interfere with the adhesion of the skin barrier. The client should use warm water or a mild, non-moisturizing soap to clean the area.
B. Pressing on the skin barrier for 30 seconds to ensure that it adheres is correct. This technique helps secure the barrier to the skin, creating a good seal and reducing the risk of leaks.
C. Cutting an opening in the skin barrier that is 1/2 inch larger than the stoma is incorrect. The opening should be about 1/8 inch larger than the stoma to ensure a snug fit, which helps protect the surrounding skin from exposure to effluent.
D. Applying a thin layer of talc powder around the stoma before placing the appliance is not appropriate. Powders are typically used to manage irritated skin but should be avoided unless specifically recommended by a healthcare provider. Overuse can interfere with the appliance’s adhesion.
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