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:

Applying wrist and leg restraints is an extreme measure and should be used only as a last resort when all other interventions have failed. Restraints can cause physical and psychological harm and should be avoided if possible.

B reason:

Moving the client to a room closer to the nurses' station is the best option. This allows for closer monitoring and quick intervention if the client's condition worsens or if they become a danger to themselves.

C reason:

Administering medication to sedate the client is not the first action to take. Sedation can mask symptoms and lead to further complications. Non-pharmacologic interventions should be considered first.

D reason:

Calling the family and asking them to stay with the client may provide comfort and help reduce confusion, but it is not a substitute for proper medical intervention and monitoring. The priority is to ensure the client is in a safe environment where they can be closely monitored by medical staff.

A. I will use lotion on irritated skin before applying a new patch in that area. B. I will remove the old patch and apply a new one in the same location. C. I will press the patch securely in place on my forearm. D. I will clean and dry the area before applying the patch.

Correct Answer is D

Explanation

A reason:

Using lotion on irritated skin before applying a new patch is incorrect. Lotion can interfere with the adhesion and absorption of the medication from the patch. It's important to keep the skin clean and dry.

B reason:

Removing the old patch and applying a new one in the same location is not recommended. The skin needs time to recover from the adhesive and medication exposure. Patches should be rotated to different areas to prevent skin irritation.

C reason:

Pressing the patch securely in place is important, but the statement is incomplete without mentioning the need to clean and dry the area first. Proper skin preparation is crucial for effective patch adhesion.

D reason:

Cleaning and drying the area before applying the patch is correct. This ensures that the patch adheres properly and that the medication is effectively absorbed through the skin.

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

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Naxlex Comprehensive Predictor Exams

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