A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.)

Select a work surface at the nurse's waist level.

Open the first flap of the sterile package toward the nurse's body.

Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap.

Place & surgical pack with a sterile drape on the work surface.

Apply sterile gloves before opening the pack

Answer and Explanation

Correct Answer : B,D

B. Open the first flap of the sterile package toward the nurse's body: When opening a sterile package, the nurse should open the first flap away from their body to prevent potential contamination from falling particles. This action helps maintain the sterility of the contents inside.

D. Place a surgical pack with a sterile drape on the work surface: Placing the surgical pack with a sterile drape on the work surface ensures that the sterile field is properly established. The sterile drape provides a clean and sterile area for the nurse to perform the dressing change.

Incorrect answers:

A. Select a work surface at the nurse's waist level: While it is important to select a work surface at an appropriate height for the nurse's comfort and ergonomics, the height of the work surface does not directly affect the maintenance of a sterile field.

C. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrap: When opening a sterile package, the nurse should grasp the inner edge of the sterile wrap to maintain the sterility of the contents. Grasping the outer edge can potentially lead to contamination of the sterile field.

E. Apply sterile gloves before opening the pack: Sterile gloves should be applied after the sterile field is established. Opening the sterile pack and setting up the sterile field should be done with clean (non-sterile) hands to avoid contaminating the contents. Once the sterile field is set up, the nurse can don sterile gloves before actually touching the sterile items.

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Correct Answer is C

Explanation

Choice A Reason:

NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.

Choice B Reason:

Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.

Choice C Reason:

A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.

Choice D Reason:

A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.

A. Administer the unit of packed RBCs over 1 hr. B. Initiate venous access with a 21-gauge needle. C. Use Y tubing with 0.9% sodium chloride when administering the transfusion D. client's first set of vital signs 1 hr. after initiating the transfusion

Correct Answer is C

Explanation

Choice A Reason:

Administering the unit of packed RBCs over 1 hour is not appropriate. Packed RBCs are usually administered over a longer period of time (typically 2 to 4 hours), as rapid infusion can lead to adverse reactions. The rate of administration should be based on institutional policy.

Choice B Reason:

Initiating venous access with a 21-gauge needle is not appropriate-. The needle size for venous access can vary based on the client's condition and the size of their veins. However, a larger gauge needle (e.g., 18-gauge or 20-gauge) is typically used for blood transfusions to ensure adequate flow.

Choice C Reason:

Blood products should be infused through administration sets designed specifcally for blood; use a Y-tubing or straight-tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage.

Choice D Reason:

The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed.

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A nurse is setting up a sterile field before performing a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply.)

Nursing Test Bank

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