A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

Hold the irrigation solution bottle 5 cm (2 in) above the sterile container.

Open the outer wrapper of the sterile package toward her body.

Place the irrigation solution bottle cap on the sterile field.

Place sterile objects at least 2.5 cm (1 in) from the edge of the sterile field.

Answer and Explanation

The Correct Answer is D

A. Holding the irrigation solution bottle 5 cm (2 in) above the sterile container is incorrect because the solution should be poured into a sterile container without contaminating the sterile field. The nurse should pour the solution from a height that avoids splashing and contamination.

B. Opening the outer wrapper of the sterile package toward her body is incorrect. The outer wrapper of a sterile package should be opened away from the body to avoid contamination of the sterile field.

C. Placing the irrigation solution bottle cap on the sterile field is incorrect. The cap should not be placed on the sterile field, as it may introduce contaminants.

D. Placing sterile objects at least 2.5 cm (1 in) from the edge of the sterile field is correct. This practice maintains the sterility of the field by preventing contamination from external sources.

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Correct Answer is D

Explanation

A. Verifying the amount of TPN solution the client is receiving every 4 hours is incorrect. While monitoring the TPN infusion rate is important, the rate and amount are typically verified at the start of the infusion and with each new bag change, not every 4 hours.

B. Placing the client in Sims' position for catheter insertion is incorrect. The preferred position for central venous catheter insertion is Trendelenburg or supine with a slight head turn, which helps dilate the veins and reduce the risk of air embolism.

C. Using clean technique when changing the catheter dressing is incorrect. Central venous catheter care requires sterile technique to prevent infections, including catheter-related bloodstream infections (CRBSIs).

D. Preparing the client for a chest x-ray to verify catheter placement is correct. A chest x-ray is required to confirm correct catheter placement before TPN administration to ensure the catheter tip is in the superior vena cava and to rule out complications like pneumothorax.

A. Remove personal protective equipment after leaving the client's room. B. Wear a gown when assisting the client with personal hygiene. C. Ensure that the negative air pressure is active for the client's room. D. Restrict the client's visitors.

Correct Answer is B

Explanation

A. Removing personal protective equipment (PPE. after leaving the room is incorrect because it should always be done before leaving the client's room to ensure the nurse does not accidentally spread the infection. Proper removal of PPE is crucial to preventing transmission.

B. Wearing a gown when assisting the client with personal hygiene is correct. MRSA is typically spread through direct contact, so wearing a gown when providing personal care (e.g., assisting with hygiene. helps prevent the spread of MRSA. Additionally, gloves and other PPE should also be worn.

C. Negative air pressure is typically required for airborne precautions, such as for clients with tuberculosis, but not for MRSA, which is transmitted via contact. Therefore, this is not necessary for MRSA care.

D. Restricting the client's visitors is not necessary unless the client has an infection that requires isolation precautions beyond what is standard for MRSA. MRSA can be controlled with contact precautions, and visitor restrictions are generally not part of standard MRSA isolation.

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A nurse is preparing a sterile field to perform a dressing change of a client's leg wound. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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