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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Wound tissue firm to palpation is a false expectation. While firmness can be an indicator of healing in some wounds, it's not a reliable indicator on its own. The appearance and characteristics of the tissue, including granulation tissue, are more significant indicators of healing.
Choice B reason:
Dry brown eschar is a false expectation. Brown eschar is often necrotic tissue that needs to be removed for the wound to heal. Its presence typically suggests a lack of healing progress.
Choice C reason:
Dark red granulation tissue is the correct expectation because it is a sign of healing in a pressure ulcer. Granulation tissue is the new tissue that forms during the healing process, and the dark red color indicates that the tissue is well-vascularized and receiving adequate blood supply, which is essential for healing.
Choice D reason:
Light yellow exudate is a false expectation. Light yellow exudate is often indicative of infection or non-healing wounds. While some exudate is normal in the healing process, its color alone doesn't necessarily indicate healing.
Correct Answer is D
Explanation
Choice A Reason:
Blurred vision is incorrectly. Blurred vision is not a common complication of immobility and is more likely related to other factors.
Choice B Reason:
Polyuria is incorrect. Increased urination (polyuria) is not directly related to immobility; it can be caused by various factors, such as fluid intake, medications, or underlying medical conditions.
Choice C Reason:
Diarrhea is incorrect. While immobility can contribute to constipation due to reduced activity and decreased bowel motility, it is not typically associated with diarrhea
Choice D Reason:
Confusion is correct. Confusion can be a potential complication of immobility in bedridden clients. Prolonged immobility can lead to reduced sensory stimulation, altered sleep patterns, and decreased cognitive engagement, which can contribute to confusion and cognitive decline.
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