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 D

Explanation

Choice A rationale

Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.

Choice B rationale

Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.

Choice C rationale

Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.

Choice D rationale

Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.

A. Use a catheter securing device to hold the catheter in place. B. Obtain urine from the drainage bag if a urinary specimen is required. C. Change the catheter bag every 3 days and as needed. D. Position the drainage bag higher than the client's bladder.

Correct Answer is A

Explanation

Choice A rationale

Securing the catheter helps prevent it from moving, which reduces the risk of urethral trauma and infection. Proper fixation is essential for patient safety and comfort.

Choice B rationale

Urine should not be obtained from the drainage bag for specimen collection as it may be contaminated. Fresh urine samples directly from the catheter port are more accurate.

Choice C rationale

Catheter bags should be changed based on clinical need, which can be more frequent than every 3 days. This ensures hygiene and reduces infection risks.

Choice D rationale

The drainage bag should be kept below the bladder level to prevent backflow of urine, which can lead to infection.

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