A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Putting on sterile gloves after preparing the sterile field

Placing the supplies on the sterile field and leaving a 1-inch perimeter

Balancing the bottle on the sterile basin while pouring the liquid

Applying a sterile gown after applying a sterile mask

Answer: C.

Answer and Explanation

The Correct Answer is C

A. Putting on sterile gloves after preparing the sterile field: This is correct aseptic practice, as sterile gloves should be donned after the sterile field is prepared to maintain sterility.

B. Placing the supplies on the sterile field and leaving a 1-inch perimeter: Maintaining a 1-inch border around the sterile field is standard practice to avoid contamination. Supplies placed within the field but outside this border remain sterile.

C. Balancing the bottle on the sterile basin while pouring the liquid: Placing a bottle on a sterile field risks contaminating the field if the bottle is not sterile. This action constitutes a break in surgical aseptic technique.

D. Applying a sterile gown after applying a sterile mask: Donning a mask before the sterile gown is appropriate to prevent contamination of the sterile gown during placement. This does not break aseptic technique.

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Correct Answer is ["A","C","E"]

Explanation

A. Activity level: Restlessness, pacing, and inability to remain seated are early neurological manifestations of water intoxication, stemming from cerebral edema related to hyponatremia. These signs often precede more severe symptoms like seizures.

B. White blood cell count: A count of 9,100/mm³ is within normal limits and does not indicate water intoxication. This value is unrelated to the dilutional effects of excessive fluid intake.

C. Sodium level: A sodium of 130 mEq/L indicates hyponatremia, which is a hallmark laboratory finding in water intoxication due to dilutional effects from excess fluid intake. Low sodium can cause neurological changes and altered mental status.

D. Potassium level: A potassium of 3.6 mEq/L is within the normal range and does not support a diagnosis of water intoxication. Potassium is less affected by acute overhydration compared to sodium.

E. Hallucinations: Responding to unseen stimuli can occur when hyponatremia causes cerebral swelling, disrupting normal brain function. In clients with psychotic disorders, excess water intake can exacerbate hallucinations or make them more pronounced.

A. Prospective audit B. Outcome audit C. Structure audit D. Concurrent audit

Correct Answer is B

Explanation

A. Prospective audit: A prospective audit evaluates care before it is provided, focusing on planned interventions rather than outcomes after discharge. It is not used to assess post-care quality.

B. Outcome audit: Outcome audits measure the results of care, such as client recovery, complication rates, or satisfaction, after interventions have been completed. This type of audit is appropriate for gathering information about quality of care following discharge.

C. Structure audit: Structure audits assess the resources, staffing, and organizational infrastructure used to deliver care. They do not measure client outcomes or post-discharge quality.

D. Concurrent audit: Concurrent audits evaluate care while it is being provided, allowing immediate feedback and corrections. They are performed during hospitalization, not after discharge.

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A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is admitting a client. Exhibits Select the 3 client findings the nurse should recognize as manifestations of water intoxication.

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