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","D"]
Explanation
A. The client is already on a daily dose of Metoprolol, and there is no indication that the dose should be increased. In fact, it is important to monitor the client's blood pressure and heart rate closely due to the potential side effects of Metoprolol.
B. This is the appropriate action since the client is allergic to penicillin, and the prescription for amoxicillin should be reviewed with the provider.
C. There is no indication from the information provided that the client requires a surgical mask when outside their room.
D. The client has been vomiting and experiencing abdominal cramping, which suggests nausea and discomfort. Requesting a prescription for an antiemetic medication is an appropriate action to address these symptoms.
E. There is no indication from the information provided that the client requires contact precautions. The client has a urinary tract infection and is not exhibiting symptoms consistent with a condition that requires contact precautions.
Correct Answer is B
Explanation
Rationale:
A. Using the incentive spirometer is important for preventing atelectasis, but it does not prevent orthostatic hypotension.
B. Dangling the legs over the side of the bed before standing helps reduce the risk of orthostatic hypotension by allowing the body to gradually adjust to the change in position.
C. Increasing protein intake is important for wound healing and tissue repair, but it does not prevent orthostatic hypotension.
D. Performing regular isometric exercises is important for maintaining muscle strength and mobility, but it does not prevent orthostatic hypotension.
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