A nurse is setting up a sterile field in a client's room.
Which of the following actions should the nurse take?
Placing the cap of a sterile solution on a clean surface with the inside facing down.
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). .
The Correct Answer is C
Choice A rationale
Placing the cap of a sterile solution on a clean surface with the inside facing down can contaminate the cap. It should be placed with the inside facing up to maintain sterility.
Choice B rationale
Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field risks contamination, as the edges are considered non-sterile. Instruments should be placed well within the sterile field.
Choice C rationale
Opening the top flap of the sterile tray package away from their body ensures that the sterile contents are not contaminated by the nurse's clothing or body, maintaining the sterility of the field.
Choice D rationale
Dropping sterile objects onto the field from a height of 5 cm (2 in) can cause contamination due to the potential for the objects to fall outside the sterile field. Objects should be placed gently onto the field without dropping them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Unequal height of the shoulders is a common indication of scoliosis. This asymmetry is often observed when a person bends forward and is a key sign during scoliosis screening.
Choice B rationale
Increased concave curve of the thoracic spine is more indicative of kyphosis, not scoliosis. Scoliosis involves a lateral curvature of the spine rather than an increase in the concave curve.
Choice C rationale
Expansion of the upper intercostal spaces is not typically associated with scoliosis. This finding is more related to respiratory conditions and does not indicate spinal curvature.
Choice D rationale
Increased convex curve of the cervical spine indicates lordosis, a condition affecting the lower spine. It is not a sign of scoliosis, which involves a lateral curve rather than a convex or concave increase.
Correct Answer is ["660"]
Explanation
Step 1: Convert all liquid intake to mL: 8 oz of milk = 8 oz × 30 mL/oz = 240 mL 10 oz of water = 10 oz × 30 mL/oz = 300 mL 4 oz of gelatin = 4 oz × 30 mL/oz = 120 mL
Step 2: Sum the liquid intake: Total intake = 240 mL + 300 mL + 120 mL = 660 mL
The nurse should record 660 mL on the I&O.
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