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:

Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, not stage 3. Stage 2 ulcers involve damage to the epidermis and part of the dermis but do not extend deeper into the subcutaneous tissue.

B reason:

Necrotic subcutaneous tissue is a hallmark of stage 3 pressure ulcers. At this stage, the ulcer extends through the full thickness of the skin and into the subcutaneous tissue, which may become necrotic. However, it does not involve bone, tendon, or muscle exposure.

C reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. Stage 4 ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, indicating deeper and more severe damage than a stage 3 ulcer.

D reason:

Blood-filled blisters are typically associated with deep tissue injury rather than stage 3 pressure ulcers. These blisters signal underlying tissue damage from sustained pressure, but they are not specific to stage 3.

A. Speak directly to the interpreter when teaching the client. B. Encourage the client to nod to indicate understanding. C. Determine the client's level of fluency in his primary language. D. Make sure a family member is present to interpret for the staff.

Correct Answer is C

Explanation

A reason:

Speaking directly to the interpreter rather than the client can create a barrier and make the client feel excluded. It is important to address the client directly and use the interpreter as a mediator to facilitate communication.

B reason:

Encouraging the client to nod to indicate understanding is not a reliable method of assessing comprehension. The client might nod out of politeness or cultural habit without fully understanding the information. Clear verbal or written feedback is more effective.

C reason:

Determining the client's level of fluency in his primary language is essential. This helps the nurse to provide appropriate communication aids and tailor the care plan to meet the client's needs. Understanding the client’s language proficiency can significantly improve the effectiveness of communication and care.

D reason:

Relying on a family member to interpret can lead to miscommunication and breaches of confidentiality. Professional interpreters should be used whenever possible to ensure accurate and unbiased translation of medical information.

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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 assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

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