A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Holding a sterile item at just above waist level

Placing a sterile dressing 5 cm (2 in) from the border of the sterile field

Opening the sterile tray by first unfolding the flap farthest from his body

Opening a sterile package over the middle of the sterile field

Answer and Explanation

The Correct Answer is D

A reason:

Holding a sterile item at just above waist level is correct practice. This helps maintain the sterility of the item by keeping it within the sterile field and preventing it from touching non-sterile surfaces.

B reason:

Placing a sterile dressing 5 cm (2 in) from the border of the sterile field is appropriate. The edges of the sterile field (usually about 2.5 cm or 1 in) are considered non-sterile, so placing items within this boundary maintains sterility.

C reason:

Opening the sterile tray by first unfolding the flap farthest from the body is correct. This technique prevents the nurse's hands and arms from passing over the sterile contents, thus maintaining the sterility of the field.

D reason:

Opening a sterile package over the middle of the sterile field is incorrect. This action can lead to contamination as the outer packaging, which is non-sterile, could contact the sterile field.

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Correct Answer is B

Explanation

A reason:

Using cold therapy for a client with peripheral vascular disease is not recommended as it can cause vasoconstriction, further impairing blood flow to already compromised extremities.

B reason:

Using cold therapy for a client with a new ankle sprain is appropriate. Cold therapy helps to reduce swelling, inflammation, and pain associated with acute injuries like sprains.

C reason:

Cold therapy for a client with a spinal cord injury is not typically indicated and may not be beneficial or could potentially cause harm, depending on the extent and location of the injury.

D reason:

Using cold therapy for a client who is unconscious requires careful consideration and is not typically indicated without a specific need. The primary concern with unconscious clients is maintaining overall care and monitoring vital signs.

A. A young adult who has a femur fracture and is in skeletal balanced suspension traction B. An older adult who has a hip fracture and is in Buck's traction C. An adolescent who has a cervical fracture and is in a halo brace D. A middle adult who has a fractured radius and an arm cast

Correct Answer is B

Explanation

A reason:

A young adult in skeletal balanced suspension traction is at risk for skin breakdown due to immobility, but they are typically more resilient compared to older adults. Age and overall health are important factors in skin integrity.

B reason:

An older adult with a hip fracture and in Buck's traction is at greatest risk for skin breakdown. Older adults have thinner, more fragile skin, and are more prone to complications from immobility. Buck's traction also limits mobility, increasing the risk of pressure ulcers.

C reason:

An adolescent in a halo brace has a risk for skin breakdown, particularly around the pin sites and under the brace, but adolescents generally have better skin resilience and healing capacity compared to older adults.

D reason:

A middle adult with a fractured radius and an arm cast is at minimal risk for skin breakdown compared to the other scenarios. This situation typically allows for more mobility and less pressure on vulnerable skin areas.

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A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to utilize cold therapy?

Correct Answer is B

Explanation

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

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As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

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