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). .

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Reminding the client that they must receive the medication as prescribed may increase their anxiety and does not address the fear of needles. It is essential to consider the client's emotional state and explore alternative solutions.

Choice B rationale

Telling the client not to worry because the pain will be temporary does not validate their fear or provide a solution to their anxiety about needles. It is important to address the client's concerns empathetically.

Choice C rationale

Requesting a change in the medication route to PO addresses the client's fear of needles directly and provides an alternative method of administration. This approach considers the client's comfort and preferences while ensuring they receive the necessary medication.

Choice D rationale

Asking one of the client's loved ones to encourage them to receive the IM medication may help, but it does not address the underlying fear of needles. It is essential to find a solution that directly addresses the client's anxiety.

A. Administer a sedative medication to the client. B. Explain to the client that they cannot leave until the surgeon discharges them. C. Have the client sign an against medical advice form. D. Tell the client that the surgeon will prescribe restraints if they try to leave.

Correct Answer is C

Explanation

Choice A rationale

Administering a sedative medication to the client without their consent is unethical and can constitute medical malpractice.

Choice B rationale

Explaining to the client that they cannot leave until the surgeon discharges them is not effective if the client insists on leaving against medical advice.

Choice C rationale

Having the client sign an against medical advice form is the appropriate action to document that the client understands the risks of leaving and is choosing to do so against the medical team's recommendations.

Choice D rationale

Telling the client that the surgeon will prescribe restraints if they try to leave is coercive and not an appropriate method to manage a client's desire to leave the hospital.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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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?