The following 4 questions pertain to this case study:

Exhibits

The post-surgical unit nurse receives the patient from the PACU. Select four priority assessments the post-surgical unit nurse should complete.

Choice A: All materials that enter the sterile field must be sterile

This is a correct principle of aseptic technique. Ensuring that all materials entering the sterile field are sterile is fundamental to preventing contamination and infection during surgical procedures. Any non-sterile item introduced into the sterile field can introduce pathogens, compromising patient safety.

Choice B: The surgical team working in the operative field must wear sterile gowns and gloves

This is another correct principle. Members of the surgical team who work directly in the operative field must wear sterile gowns and gloves to create a barrier against microorganisms. This practice helps maintain the sterility of the surgical environment and protects both the patient and the healthcare providers.

Choice C: The sterile package is contaminated once it has been opened

This statement is incorrect. A sterile package is not necessarily contaminated once it has been opened, provided it is opened correctly and the contents are handled using aseptic techniques. Proper opening and handling ensure that the sterility of the contents is maintained.

Choice D: The circulating nurse must wear sterile gowns and gloves

This statement is incorrect. The circulating nurse does not need to wear sterile gowns and gloves because they do not work directly in the sterile field. Instead, they assist by providing necessary supplies and support from outside the sterile area.

Choice E: Tables are sterile only at tabletop level. Items extending beneath this level are contaminated

This is a correct principle. In the operating room, the sterility of tables is maintained only at the tabletop level. Any items that extend below this level are considered contaminated and should not be used in the sterile field.

Choice F: A wide margin of safety is maintained between sterile and unsterile fields

This is also a correct principle. Maintaining a wide margin of safety between sterile and unsterile fields helps prevent accidental contamination. This practice ensures that sterile areas remain uncontaminated by non-sterile items or personnel.

Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.