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?
Set up the sterile field 5 cm (2 in) below waist level.
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.
The Correct Answer is D
A: The sterile field should be set up at or above waist level to prevent contamination from higher surfaces, not below.
B: The outer edge (about 2.5 cm or 1 inch) of the sterile field is considered non-sterile, so placing the sterile dressing close to the edge risks contamination.
C: The outermost flap of the sterile kit should be opened away from the body to avoid reaching over the sterile field, which could lead to contamination.
D: The cap should be placed sterile side up to maintain its sterility if it needs to be reapplied to the solution bottle.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
B. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerging the feet in ice water is not recommended as it can cause vasoconstriction and shivering, which may increase the body temperature. Instead, tepid sponging and providing a cool environment can be beneficial.
D. Covering the adolescent with a thermal blanket would retain body heat and exacerbate hyperthermia, counteracting efforts to lower the body temperature.
Correct Answer is C
Explanation
A. While a temperature elevation in a client with Clostridium difficile requires assessment, it is not as urgent as potential cardiac ischemia.
B. Pain assessment in a client with a femur fracture is important but does not take priority over potential cardiac issues.
C. Left shoulder pain with S-T elevation on an ECG can indicate myocardial infarction (MI), a life-threatening condition requiring immediate assessment and intervention.
D. Orthostatic hypotension and pitting edema, while concerning, do not indicate an acute, life-threatening condition that requires immediate assessment in this scenario.
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