A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take?

Pour liquid by holding the bottle with the label facing the sterile field.

Prepare the sterile field 5 cm (2 in) below the level of the waist.

Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field.

Open the outermost flap of the wrapper toward the body.

Answer and Explanation

The Correct Answer is C

A. Pour liquid by holding the bottle with the label facing the sterile field: When pouring solutions onto a sterile field, the label should face the nurse’s hand, not the sterile field. This prevents the liquid from running down the bottle and obscuring or washing off the label, which maintains accurate identification of the solution while protecting the sterile field.

B. Prepare the sterile field 5 cm (2 in) below the level of the waist: The sterile field should be set up at or above waist level to prevent accidental contamination. Positioning it below waist level increases the risk of droplets, contact with nonsterile surfaces, or accidental touches, compromising sterility.

C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field: Maintaining this distance ensures that the fluid is poured without splashing or touching the sterile field with the bottle, which reduces contamination risk. This technique balances control and safety while preserving sterility during preparation or dressing changes.

D. Open the outermost flap of the wrapper toward the body: The outermost flap should be opened away from the body to prevent reaching over the sterile field, which could result in accidental contamination. Opening toward the body increases the chance that clothing or hands might contact the sterile surface.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Have several small meals during the day.": Smaller, more frequent meals reduce the work of breathing required during eating, as large meals can increase diaphragmatic pressure and exacerbate dyspnea in clients with COPD. This strategy helps maintain adequate nutritional intake without causing fatigue or shortness of breath.

B. "Limit snacking between meals.": Restricting snacks may lead to insufficient caloric intake, which can worsen weight loss and muscle weakness common in COPD. Frequent small meals, including healthy snacks, are preferred to maintain energy levels and support respiratory muscle function.

C. "Eat one food at a time during meals.": While simplifying meals can help some clients, the key intervention for dyspnea management during meals is controlling meal size and frequency. Focusing on single foods does not significantly reduce the work of breathing.

D. "Consume a full-liquid diet.": A full-liquid diet is generally unnecessary unless swallowing difficulties exist. Liquids alone may not provide sufficient calories or protein for clients with increased energy expenditure due to COPD and may contribute to malnutrition.

A. "You can use an adhesive remover when changing the colostomy skin barrier." B. "You should scrub the skin around the colostomy when cleaning." C. "You will need a device to suction stool from the colostomy bag." D. "You should empty the colostomy bag when it is three-fourths full,"

Correct Answer is A

Explanation

A. "You can use an adhesive remover when changing the colostomy skin barrier.": Adhesive removers are appropriate to decrease trauma to the peristomal skin during appliance changes. Frequent removal of skin barriers can cause mechanical stripping, leading to irritation, denudation, and increased risk of infection. Using a gentle adhesive remover helps preserve skin integrity, which is essential for maintaining a proper seal and preventing leakage of effluent.

B. "You should scrub the skin around the colostomy when cleaning.": The peristomal skin should be cleaned gently with warm water and mild soap if needed, avoiding vigorous scrubbing. Scrubbing can cause friction injury and disrupt the epidermal barrier, increasing susceptibility to irritation from stool enzymes.

C. "You will need a device to suction stool from the colostomy bag.": Colostomy output drains passively into the pouch by gravity and peristalsis; suction devices are not used. Introducing suction could damage the stoma mucosa or disrupt the pouch seal. Routine care involves emptying and changing the appliance rather than mechanically removing stool.

D. "You should empty the colostomy bag when it is three-fourths full,": Colostomy pouches are generally emptied when they are one-third to one-half full to prevent excessive weight pulling on the skin barrier. Allowing the bag to fill to three-fourths increases the risk of leakage and detachment due to increased pressure and weight.

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A nurse is setting up a sterile field prior to performing a dressing change. Which of the following actions should the nurse take?

Nursing Test Bank

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