A nurse is setting up a sterile field to perform wound irrigation for a client.
Which of the following actions should the nurse take when pouring the sterile solution?
Place sterile gauze over areas of spilled solution within the sterile field.
Hold the irrigation solution bottle with the label facing away from the palm of the hand.
Remove the cap and place it sterile-side up on a clean surface.
Hold the bottle in the center of the sterile field when pouring the solution.
The Correct Answer is C
The correct answer is c. Remove the cap and place it sterile-side up on a clean surface.
Choice A rationale:
Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up
Choice B rationale:
Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field
Choice C rationale:
Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution
Choice D rationale:
Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.
Correct Answer is B
Explanation
The correct answer is choice b. Remove the device from the room.
Choice A rationale:
Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.
Choice B rationale:
Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.
Choice C rationale:
Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.
Choice D rationale:
Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.
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