A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.

Open the outermost flap of the sterile kit toward the body.

Place the cap from the solution sterile side up on a clean surface.

Set up the sterile field 5 cm (2 in) below waist level.

Answer and Explanation

The Correct Answer is C

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

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Correct Answer is C

Explanation

A) A lack of empathy is more commonly associated with antisocial personality disorder rather than obsessive-compulsive personality disorder (OCPD). Individuals with OCPD may have difficulty expressing emotions, but they often maintain a sense of morality and are capable of empathy, albeit it may be less visible due to their rigid thinking.

B) Lability, or rapid mood changes, is typically seen in borderline personality disorder rather than OCPD. Clients with obsessive-compulsive personality disorder often exhibit a stable mood but may be seen as overly serious or focused on order and control.

C) Clients with obsessive-compulsive personality disorder tend to be goal-oriented. They often exhibit perfectionism, meticulousness, and a strong need for orderliness, which drives their behavior. This focus on goals and tasks is a hallmark of OCPD, distinguishing it from other personality disorders that may not have this same level of achievement orientation.

D) Provocative behavior is more indicative of borderline or histrionic personality disorders. Individuals with OCPD typically do not engage in attention-seeking or provocative behaviors; instead, they are more reserved and focused on their own rigid standards and tasks.

A. A client who received a Mantoux test 48 hr ago and has an induration. B. A client who is taking warfarin and has started to breastfeed. C. A client who is taking bumetanide and reports an increase in urinary frequency. D. A client who is scheduled for a colonoscopy and is taking sodium phosphate.

Correct Answer is B

Explanation

A. A client who received a Mantoux test 48 hr ago and has an induration: The presence of induration is expected in a positive Mantoux test and does not necessarily require follow-up unless the induration is large, indicating possible tuberculosis exposure.

B. A client who is taking warfarin and has started to breastfeed: This situation requires follow-up care. While warfarin can be used during breastfeeding, careful monitoring is needed due to potential effects on the infant and the necessity of maintaining therapeutic INR levels.

C. A client who is taking bumetanide and reports an increase in urinary frequency: This is a normal side effect of bumetanide, a diuretic, and does not require follow-up unless there are additional concerning symptoms.

D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: This is a common preparation for a colonoscopy, and while electrolyte balance should be monitored, it does not inherently indicate a need for follow-up care unless there are specific issues reported.

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A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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