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:

Asking the client to look down when instilling the solution is incorrect. The client should be asked to look up to expose the lower conjunctival sac, which is the proper site for administering eye drops.

B reason:

Holding the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac is correct. This distance helps to prevent contamination of the dropper and ensures accurate delivery of the medication into the eye.

C reason:

Approaching the client's eye from below is not standard practice. The eye dropper should be held above the eye to allow gravity to assist in the administration of the drops.

D reason:

Instilling the drops into the inner canthus is incorrect. The drops should be placed into the lower conjunctival sac to ensure proper absorption and effectiveness of the medication.

A. Contact B. Airborne C. Neutropenic D. Droplet

Correct Answer is C

Explanation

A reason:

Contact precautions are used to prevent the spread of infections that are transmitted by direct or indirect contact with the patient or the patient's environment. These precautions are not specific to the needs of a client with a stem-cell transplant, who is more susceptible to infections due to a weakened immune system.

B reason:

Airborne precautions are used for infections that can be spread through the air over long distances, such as tuberculosis, measles, and chickenpox. This is not the primary concern for a client with a stem-cell transplant.

C reason:

Neutropenic precautions are correct. These are specific infection-control measures used to protect immunocompromised patients, such as those who have undergone an allogeneic hematopoietic stem-cell transplant. These precautions include measures to prevent infection from external sources because the patient’s immune system is significantly weakened.

D reason:

Droplet precautions are used to prevent the spread of infections that are transmitted through large respiratory droplets, such as influenza or meningitis. While important, these precautions are not tailored to the specific needs of a stem-cell transplant patient, who requires more stringent infection prevention measures.

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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 preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Correct Answer is C

Explanation

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