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 B
Explanation
Choice A rationale:
Placing an oval corn pad over toes and removing it weekly may increase the risk of infection and skin breakdown. Continuous use of pads can trap moisture, potentially leading to complications for individuals with diabetes.
Choice B rationale:
Applying lotion to soften calluses without putting lotion between the toes is correct. Moisturizing can help prevent dry skin, but it's essential to avoid moisture between the toes to prevent fungal infections. The emphasis on proper foot care aligns with diabetes management, where foot health is crucial.
Choice C rationale:
Using over-the-counter liquid medication to remove corns without professional guidance can lead to complications and skin damage. It's important to involve healthcare providers in the management of foot issues in individuals with diabetes.
Choice D rationale:
Soaking feet in warm water daily can contribute to moisture, increasing the risk of fungal infections. It's generally not recommended for individuals with diabetes, emphasizing the importance of avoiding excessive moisture.
Correct Answer is B
Explanation
- Choice A Rationale: This response may provide factual information, but it does not address the client's immediate emotional concern about the colostomy bag, which can lead to feelings of being dismissed or not heard.
- Choice B Rationale: This is an empathetic response that uses reflective listening. It acknowledges the client's concern directly and invites the client to express more about their feelings and concerns, which can help in providing emotional support and further discussion.
- Choice C Rationale: This response delays addressing the client's concern, which may increase anxiety. It is important to discuss concerns as they arise to provide reassurance and to ensure that the client feels supported and understood.
- Choice D Rationale: This response might help the client to connect with others' experiences, but it does not directly address the client's concern about themselves. It could be seen as deflecting the conversation away from the client's personal worries.
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