A nurse is performing a sterile dressing change.
If new sterile items or supplies are needed, how can they be added to the sterile field?
Carefully handle new sterile items with clean hands.
Consider the outer half inch border of the sterile field to be contaminated.
Clean hands and wear latex gloves before grabbing new supplies.
Use sterile forceps to add sterile supplies as needed.
The Correct Answer is D
Choice A rationale
Handling sterile items with clean hands is a violation of surgical asepsis principles. Even if hands are washed, they are not sterile and will immediately contaminate any sterile item they touch. Sterile objects must only come into contact with other sterile objects to maintain the integrity of the sterile field. Using clean hands would introduce microorganisms to the supplies, increasing the patient's risk for a healthcare-associated infection during the dressing change or surgical procedure.
Choice B rationale
While it is true that the outer one-inch border of a sterile field is considered contaminated, this principle explains the boundaries of the field rather than the method for adding new supplies. Understanding the border helps the nurse know where it is safe to place items, but it does not provide a mechanism for introducing new sterile items into the center of the field during a procedure. Correct placement requires dropping items or using a sterile tool to move them.
Choice C rationale
Standard latex or nitrile gloves are clean but not sterile. Grabbing new sterile supplies with clean gloves will contaminate the supplies and subsequently the entire sterile field if those supplies are placed upon it. To handle sterile items directly, the nurse must perform a surgical hand scrub and don sterile gloves. Using regular gloves is appropriate for many tasks, but it is insufficient for maintaining the strict environment required for a sterile dressing change.
Choice D rationale
Using sterile forceps is a correct and recognized method for adding or rearranging items on a sterile field. The forceps, being sterile themselves, can safely touch other sterile items without introducing contaminants. This allows the nurse to maintain the aseptic chain while adjusting the layout of the field or adding small components like gauze or instruments. It is a precise way to manage the sterile area without needing to change gloves or risk accidental contact.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Washing hands for sixty seconds is generally reserved for surgical scrubbing or situations involving high-level contamination with specific pathogens. For routine hand hygiene when hands are not visibly soiled, such a long duration is unnecessary and can lead to skin irritation or breakdown. Prolonged exposure to water and soap strips natural oils from the skin, compromising the epidermal barrier, which is the body's first line of defense against infection.
Choice B rationale
The Centers for Disease Control and Prevention and World Health Organization recommend scrubbing hands for at least 20 seconds to effectively mechanical remove transient microorganisms. This duration allows sufficient time for surfactants in soap to emulsify fats and proteins found in microbial membranes, facilitating their detachment from the skin surface. Proper friction during these 20 seconds ensures that all surfaces, including interdigital spaces and subungual areas, are adequately decontaminated to prevent cross-transmission.
Choice C rationale
A 45 second scrub exceeds the standard clinical recommendation for non-surgical hand hygiene. While longer scrubbing is not harmful in terms of cleanliness, it does not provide a significantly higher reduction in transient flora compared to a 20 second scrub for non-soiled hands. In a fast-paced clinical environment, adherence to hand hygiene protocols is higher when the required time is realistic and based on the minimum effective duration needed to break the chain of infection.
Choice D rationale
Scrubbing for two minutes is far beyond the requirement for standard hand hygiene and is typically associated with pre-operative surgical hand preparation using antiseptic agents. Requiring a two minute wash for every patient encounter would be impractical for healthcare workers and would likely result in significant skin damage over time. Dermatitis caused by over-washing can actually harbor more bacteria, increasing the risk of healthcare-associated infections rather than decreasing them in the clinical setting.
Correct Answer is C
Explanation
Choice A rationale
Safety event reports, also known as incident reports, are designed to record facts rather than subjective opinions or future recommendations. While hospitals use these reports for quality improvement and to develop prevention strategies, the individual filling out the report should focus on what actually happened. Adding suggestions within the primary report can sometimes complicate the objective nature of the legal document. Prevention analysis is usually handled by a separate risk management committee during follow-up reviews.
Choice B rationale
Discussing the report details with a confused client before documenting is often counterproductive and may lead to inaccurate information. A confused client may not have a reliable memory of the fall, and their input might be influenced by their cognitive state. The nurse's primary duty is to assess the client for injuries immediately. Once the client is safe, the nurse should document the objective findings and observed events directly, rather than waiting for a discussion with the client.
Choice C rationale
Accuracy in the medical record is essential for legal and clinical reasons after a fall. The nurse must document the objective facts of the event, including the time, the client's position when found, and any immediate physical findings or symptoms. Additionally, the nurse must record the interventions taken, such as notifying the physician and the client's subsequent response. This provides a clear timeline and evidence that the standard of care was followed to protect the client.
Choice D rationale
Providing minimal information is a poor practice that can lead to missing critical data needed for root cause analysis. A safety report must be thorough and include all relevant environmental factors, such as whether the bed rails were up or if the floor was wet. Omitting details can mask patterns that contribute to falls across a unit. Comprehensive reporting is the only way to ensure that healthcare systems can learn from errors and improve patient safety outcomes.
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