A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)

A. Despite the client reporting thirst and frequent urination, the client's urine specific gravity of 1.010 is within the normal range (1.005 to 1.030). The above symptoms could be associated with the hyperglycemia.

B. There is no indication of a pneumothorax in the nurse's notes or diagnostic results.

C. The casual glucose level of 300 mg/dL is significantly above the normal range (less than 200 mg/dL), indicating hyperglycemia.

D. The client’s WBC level is elevated, 11,500/mm3 (5,000 to 10,000/mm3) thus indicating an infection.

Rationale:

A. Allowing sterile forceps to rest in a container of sterile does not affect the sterility of the field.

B. Pouring sterile solution with the bottle held over the field is an inappropriate technique since it breaches the sterility of the field.

C. Placing unnecessary sterile items on the field is not ideal, but it does not indicate contamination of the surgical field.

D. The handle of a pair of sterile scissors resting 5 cm (2 in) from the field's edge does not indicate contamination of the surgical field. The scissors should be placed within easy reach of the nurse but should not touch non-sterile items.