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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Suggesting a support group helps the client address emotional resistance to the colostomy through peer support. This fosters psychological adjustment, reduces stigma, and promotes self-management by sharing experiences, aligning with evidence-based strategies to improve coping and adaptation in clients with new ostomies.
Choice B reason: Encouraging avoidance of negative feelings dismisses the client’s emotional response, hindering psychological adaptation. Accepting a colostomy requires processing grief and fear. Suppressing emotions delays coping, as psychological adjustment involves acknowledging feelings to integrate the stoma into the client’s self-image effectively.
Choice C reason: Instructing the partner to assume colostomy care undermines the client’s autonomy and delays self-management. Independence in stoma care is critical for psychological and practical adaptation. Dependency may hinder adjustment, as clients need to develop skills to manage their condition independently.
Choice D reason: Transferring to a rehabilitation facility is premature without trying in-hospital education or support groups. Most clients learn stoma care with nursing guidance. Transfer disrupts care continuity and may increase distress, failing to address emotional resistance directly, unlike peer support interventions.

A. A client who has multiple facial lacerations. B. A client who has a puncture wound in the right lower lung. C. A client who has full-thickness burns over the lower extremities. D. A client who has an open compound fracture of the humerus.

Correct Answer is A

Explanation

Choice A reason: Multiple facial lacerations, if not affecting airway or causing severe bleeding, are minor injuries in triage (green tag). These clients can wait for treatment without immediate risk, aligning with disaster triage principles, making this the correct classification.
Choice B reason: A puncture wound to the lung is life-threatening, potentially causing pneumothorax or hemothorax, requiring urgent intervention (red tag). This is not a minor injury, so it does not qualify for a green tag, making it incorrect.
Choice C reason: Full-thickness burns over the lower extremities are severe, requiring immediate fluid resuscitation and specialized care (red or yellow tag). These are not minor injuries, so this client does not fit green tag criteria, making it incorrect.
Choice D reason: An open compound fracture of the humerus is a significant injury with risks of infection and bleeding, requiring prompt surgical intervention (yellow or red tag). It is not minor, so it does not qualify for a green tag, making it incorrect.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a newly created colostomy. The client’s partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

Correct Answer is A

Explanation

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