A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Positions the wrapped package on the bedside table so the outer flap is away from her.

Holds gauze packages 15 cm (6 in) above the sterile field.

Holds a bottle of solution with the label away from the palm of the hand.

Wears sterile gloves when moving sterile items on the sterile field.

Answer and Explanation

The Correct Answer is C

A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.

B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.

C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.

D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.

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Correct Answer is D

Explanation

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

A. Emphasize the significance of the information. B. Continue with the discussion C. Stop the instructions to see what is on the floor. D. Move closer to the client for eye contact.

Correct Answer is B

Explanation

A. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.

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A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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