A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field

Opening the top flap of the sterile tray package away from their body

Dropping sterile objects onto the field from a height of 5 cm (2 in)

Placing the cap of a sterile solution on a clean surface with the inside facing down

Answer and Explanation

The Correct Answer is B

A)   Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field - Sterile items should be kept within the confines of the sterile field to maintain sterility.
B)   Opening the top flap of the sterile tray package away from their body - Opening the sterile package away from the body helps prevent contamination from airborne particles or droplets.
C)   Dropping sterile objects onto the field from a height of 5 cm (2 in) - Dropping sterile objects can create air currents that may introduce contamination to the sterile field, for instance, through splashing.
D)   Placing the cap of a sterile solution on a clean surface with the inside facing down

- Sterile items should be handled with care to maintain sterility, and placing the cap with the inside facing down may introduce contamination. The inside of the cap should face up.

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Correct Answer is C

Explanation

A) "His partner has been visiting." - While social support is important, this information is not essential for the receiving unit's immediate care planning.
B) "He is voiding adequately." - While relevant to the client's overall condition, this information may not be a priority for the receiving unit unless there are specific urinary concerns.
C) "He is allergic to sulfa." - Allergy information is critical for ensuring safe medication administration and should be included in the transfer report.
D) "He appears anxious about the transfer." - While the client's emotional state is important, it may not be the most pertinent information for the receiving unit's immediate care planning.

A. Unequal height of the shoulders B. Expansion of the upper intercostal spaces C. Increased convex curve of the cervical spine D. Increased concave curve of the thoracic spine

Correct Answer is A

Explanation

A) Unequal height of the shoulders - This finding is characteristic of scoliosis, as the curvature of the spine may cause one shoulder to appear higher than the other.
B) Expansion of the upper intercostal spaces - Expansion of the intercostal spaces is not a typical finding in scoliosis and may indicate other respiratory or musculoskeletal conditions.
C) Increased convex curve of the cervical spine - While scoliosis can affect the entire spine, an increased convex curve in the cervical spine is not typically associated with scoliosis.
D) Increased concave curve of the thoracic spine - While scoliosis often involves a lateral curvature of the spine, an increased concave curve of the thoracic spine alone may not be indicative of scoliosis.

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A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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