A nurse is preparing a sterile field to assist with suturing a client's laceration. Which of the following actions should the nurse perform?
Pour the sterile solution with the bottle held 20 cm (8 in) above the sterile bowl.
Apply sterile gloves before opening the bottle of sterile solution.
Place the lid of the sterile solution bottle face down on the sterile drape.
Hold the bottle of sterile solution so that the label is facing the palm of the hand.
The Correct Answer is D
A. The bottle should be held 5–10 cm (2–4 in) above the sterile field to prevent splashing, not 20 cm.
B. Sterile gloves are applied after the sterile field is set up; they are not required before opening the bottle.
C. The lid of the sterile solution bottle should be placed upside down on a clean surface, not on the sterile drape, to prevent contamination.
D. Holding the bottle with the label facing the palm protects the label from getting wet or contaminated while pouring the solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
the nurse should hold the vial upside down and insert the needle into the center of the rubber stopper.
Choice B rationale:
Holding the syringe at a 45° angle to verify dosage is not a standard practice during the preparation of medication from a vial. The syringe should be held upright at 90° to accurately measure the desired dosage.
Choice C rationale:
Holding the syringe so that bubbles collect at the level of the plunger is incorrect. The nurse should hold the syringe so that bubbles collect at the level of the needle tip. Bubbles should be expelled from the syringe before withdrawing the medication to ensure accurate dosage.
Choice D rationale:
Injecting air into the vial with the eye of the needle immersed in the fluid is correct. This action prevents the formation of bubbles and ensures accurate dosage.
Correct Answer is C
Explanation
Choice A rationale:
Referring the client to a breast cancer support group is a helpful intervention, but it may not be the first action.
Choice B rationale:
Providing the client with a mirror to look at her mastectomy incisions may be done later in the healing process.
Choice C rationale:
Identifying the impact of the mastectomy on the client's body image is the first action to address the client's emotional needs and concerns.
Choice D rationale:
Encouraging the client to assist with her dressing changes may be appropriate but does not address the emotional aspect of the client's response.
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