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 B

Explanation

A) Hearing acuity intact - Intact hearing acuity does not directly increase the risk for potential client injuries.
B) Oriented to person only - Being oriented to person only may indicate confusion or disorientation, which can increase the risk for potential client injuries due to impaired decision-making or awareness of surroundings.
C) Full range of motion bilateral lower extremities - Having a full range of motion in the lower extremities does not directly increase the risk for potential client injuries.
D) Ability to use call light - The ability to use a call light indicates the client's ability to seek assistance, which reduces the risk for potential client injuries.

A. Stand on the client's stronger side when moving the client into the chair. B. Flex hips and knees when assisting the client to a standing position. C. Raise the bed to waist level before moving the client. D. Pivot on the foot farthest from the bed when assisting the client into the chair.

Correct Answer is A

Explanation

A. Stand on the client's stronger side when moving the client into the chair- Standing on the stronger side provides better support and stability during the transfer, reducing the risk of injury.
B. Flex hips and knees when assisting the client to a standing position- Flexing the hips and knees helps maintain a stable and balanced posture during the transfer but is not specific to the client's left-sided weakness.
C. Raise the bed to waist level before moving the client- Adjusting the bed height can facilitate the transfer process, but it is not directly related to the client's left-sided weakness.
D. Pivot on the foot farthest from the bed when assisting the client into the chair- Pivoting on the foot farthest from the bed allows for a smooth and controlled transfer motion but does not address the client's left-sided weakness specifically.

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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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