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 C

Explanation

A reason:

The client should hold the cane on the strong side, not the weak side. This provides better support and stability when ambulating.

B reason:

The grip of the cane should be level with the client's wrist crease, not the waist. This ensures proper ergonomic support and reduces the risk of strain or injury.

C reason:

When the client moves, he should move the cane forward first. This provides support and stability before taking a step with the weaker leg.

D reason:

The client should first move the weak leg, not the strong one. The cane and the weak leg should move together to provide support and balance during ambulation.

A. Every 2 hours while the client is awake. B. Immediately before the client has a meal. C. When the client has the urge to defecate. D. After the client feels abdominal cramping.

Correct Answer is C

Explanation

A reason:

Taking the client to the toilet every 2 hours while the client is awake is not practical for bowel training, as it does not align with the body’s natural elimination patterns. This approach may cause unnecessary frustration and does not help establish a regular bowel routine.

B reason:

Taking the client to the toilet immediately before a meal is not necessarily effective for bowel training, as the gastrocolic reflex, which stimulates bowel movement, typically occurs after eating rather than before.

C reason:

Taking the client to the toilet when they have the urge to defecate is correct. This approach encourages the recognition and response to the body’s natural signals, helping to establish a regular bowel routine and improve bowel function over time.

D reason:

Waiting until the client feels abdominal cramping may be too late, as cramping can indicate an urgent need to defecate, potentially leading to discomfort or incontinence. It is better to respond to earlier signals of the need to defecate.

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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

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Explanation

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Correct Answer is C

Explanation

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