A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
Uses a sterile-gloved hand to adjust the back of the sterile gown
Uses sterile forceps to pack sterile gauze into the wound
Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
Sets up the sterile field 30 min prior to performing the dressing change
The Correct Answer is B
Using a sterile pair of forceps to pack a sterile gauze maintains sterility to reduce risk of wound contamination and infection.
A. The back of the sterile gown is considered unsterile and using sterile gloves to touch it breaches sterility.
C. Any part of the sterile field that is within 1 inch from the edge is considered contaminated D. Prolonged exposure of sterile tools to airborne microorganisms can lead to contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A red tag is assigned to clients with a serious life-threatening condition that requires immediate intervention. According to the ABCs of basic life support, the client with a compromised has a life-threatening condition as it might lead to death if left unaddressed.
A, B, C have concerns that requires attention but airway should be addressed first. The other clients have less urgent conditions that can be assigned lower priority tags.
Correct Answer is D
Explanation
The client with slurred speech and confusion could be experiencing a stroke. Recognition of a stroke is an emergency as some forms of stroke requires immediate intervention that is only amenable within a specific time period.
A. A closed femur fracture may have bleeding and other neurovascular damage but this is not as life threatening as a stroke
B. Superficial burns of 10% is likely to have severe pain. The extent of dehydration is minimal
C. Severe vomiting and diarrhea with tachycardia is a sign that the body is compensating for the fluid loss at this point and, therefore, not of highest priority.
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