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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

this is not enough to prevent clogging and ensure adequate hydration.

Choice B rationale:

Combining medications with the formula in the feeding bag may alter the absorption and effectiveness of the medications.

Choice C rationale:

Diluting crushed medications with sterile water individually ensures accurate dosing and avoids potential interactions.

Choice D rationale:

Mixing medications in a single syringe may cause interactions between medications and compromise accurate dosing while preventing obstruction.

A. Palpate the abdomen. B. Auscultate bowel sounds. C. Administer an antiemetic. D. Offer pain medication.

Correct Answer is B

Explanation

Choice A rationale:

Palpating the abdomen should be done cautiously and is not the first action, especially if an abdominal obstruction is suspected.

Choice B rationale:

Auscultating bowel sounds is the first action the nurse should take when assessing a client with right lower quadrant pain, nausea, and vomiting. Bowel sounds can provide information about bowel motility and potential obstruction. The nurse should use the least invasive assessment technique first, which is auscultation.

Choice C rationale:

Administering an antiemetic may be necessary, but assessing bowel sounds takes precedence in the initial assessment.

Choice D rationale:

Offering pain medication is not the first action, as the cause of the symptoms needs to be identified before pain management. Pain medication could mask the symptoms and delay diagnosis.

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