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.

Answer and Explanation

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.

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Correct Answer is ["D","E"]

Explanation

Rationale:

A. These neurological findings are within normal limits and do not require immediate follow-up.

B. These musculoskeletal findings are not indicative of an emergency and can be addressed during routine care.

C. Clear lung sounds are a normal finding and do not require immediate follow-up.

D. An irregular heart rate may indicate an arrhythmia or other cardiovascular issue that requires further assessment and intervention.

E. Hyperactive bowel sounds can indicate a variety of gastrointestinal issues, including bowel obstruction or ileus, which may require immediate intervention or further investigation.

A. Open the outside cover of the sterile kit and remove the dust cover B. Grasp the outermost flap of the sterile kit while opening away from the body. C. Prepare a dry work surface above the waist level D. Open the innermost lower flap of the sterile kit while standing away from the sterile field E. Open each side flap of the sterile kit individually while pulling to the side

Correct Answer is C,A,B,D,E

Explanation

A. Opening the outside cover of the sterile kit and removing the dust cover exposes the sterile supplies within the kit.
B. Grasping the outermost flap of the sterile kit while opening away from the body helps maintain the sterility of the contents within the kit.

C. Preparing a dry work surface above the waist level ensures that the sterile field is established at a proper height and that the nurse's hands are at the appropriate level for working within the sterile field.
D. Opening the innermost lower flap of the sterile kit while standing away from the sterile field allows the nurse to access the sterile supplies without contaminating the sterile field.
E. Opening each side flap of the sterile kit individually while pulling to the side further establishes the sterile field and provides access to the sterile supplies.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["D","E"]

Explanation

50. A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Correct Answer is C,A,B,D,E

Explanation

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