A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?
Open the sterile drape by touching the inner surface first.
Place sterile items within a 1-inch border of the drape.
Hold sterile instruments above the waist and away from the body.
Pour sterile solution directly from a container held 12 inches above.
The Correct Answer is C
Choice A reason: Touching the inner surface of a sterile drape first contaminates it, as only sterile gloves should contact this area. Outer edges are handled to maintain sterility, so this action violates sterile technique, making it incorrect.
Choice B reason: Placing items within a 1-inch border of the drape is incorrect, as this border is considered non-sterile. Sterile items must be placed centrally to avoid contamination, so this action breaches sterile field principles, making it incorrect.
Choice C reason: Holding sterile instruments above the waist and away from the body maintains sterility, as areas below the waist or close to the body are considered contaminated. This aligns with aseptic technique, making it the correct action for sterile field preparation.
Choice D reason: Pouring solution from 12 inches above risks splashing, contaminating the sterile field. Solutions should be poured from 4-6 inches to control flow and maintain sterility, so this action is incorrect and unsafe for sterile procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.
Correct Answer is D
Explanation
Choice A reason: Ritualistic behavior is linked to obsessive-compulsive personality disorder, not narcissistic personality disorder (NPD). NPD involves self-focused grandiosity, not repetitive rituals driven by anxiety. These distinct psychological mechanisms make ritualistic behavior an unlikely finding in clients with NPD during assessment.
Choice B reason: Suspiciousness is characteristic of paranoid personality disorder, not NPD. While NPD clients may distrust due to ego threats, this is secondary to their grandiose self-view. Suspicion is not a core NPD trait, as their focus is on admiration, not pervasive mistrust.
Choice C reason: Preoccupation with aging is not a primary NPD feature. NPD clients focus on idealized self-image, but aging fears are more tied to body dysmorphic disorder or general anxiety. This preoccupation is not a diagnostic criterion for NPD in psychological assessments.
Choice D reason: A grandiose sense of self is a core NPD feature, marked by exaggerated self-importance and entitlement. Driven by fragile self-esteem, this trait leads to behaviors like boasting, as defined in DSM-5 criteria, making it an expected finding during assessment of NPD clients.
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