The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?

Open the sterile drape and place it on the table

Put on sterile personal protective equipment

Clean a work surface and raise it to waist level

Arrange sterile instruments on the sterile field

Answer and Explanation

The Correct Answer is C

A. Open the sterile drape and place it on the table: Opening sterile supplies before preparing the environment increases the risk of contamination. The surface must be clean, dry, and positioned appropriately before any sterile items are opened. Environmental preparation precedes establishing the sterile field.

B. Put on sterile personal protective equipment: Sterile gloves and PPE are donned after the sterile field is set up, not before. Donning them too early increases the risk of contamination during setup. Hand hygiene and environment preparation come first.

C. Clean a work surface and raise it to waist level: The work surface must be disinfected and positioned at or above waist level to maintain visibility and prevent contamination. Sterile fields kept below waist level are considered contaminated. Preparing the environment is the first step in sterile setup.

D. Arrange sterile instruments on the sterile field: Sterile instruments are handled only after the sterile field has been properly established. Placing instruments occurs later in the setup sequence. This action depends on prior preparation of the field.

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Correct Answer is D

Explanation

A. A client who needs assistance ambulating in the hall: Helping with ambulation is important to prevent falls, but it does not indicate an immediate threat to life or safety. This task can be delegated or scheduled after addressing higher-priority needs.

B. A client with pain 4/10 requesting pain medication: Moderate pain requires timely management to promote comfort, but it is not an urgent threat to physiologic stability. Pain management can follow assessment of clients with acute changes.

C. A client with a scheduled wound dressing change: Routine wound care is necessary for healing and infection prevention, but it is a planned intervention that does not indicate an urgent change in status. It can be scheduled after clients with acute concerns are addressed.

D. A client with a change in their level of consciousness: Altered mental status can indicate hypoxia, infection, intracranial pathology, or metabolic disturbance. This represents an immediate, potentially life-threatening change and requires rapid assessment and intervention.

Correct Answer is []

Explanation

Rationale for correct choices

• Standard precautions: Clients with HIV who are asymptomatic and not showing signs of infection require standard precautions. These precautions are used for all patients to prevent transmission of bloodborne pathogens and other infections, regardless of diagnosis. Standard precautions focus on protecting healthcare workers and preventing cross-contamination.

• Wear gloves when anticipating contact with bodily fluids: Gloves prevent exposure to blood, bodily fluids, and other potentially infectious materials. This is a fundamental part of standard precautions, reducing the risk of transmission of HIV and other pathogens during routine care.

• Perform hand hygiene before and after client care: Hand hygiene is the most effective method for preventing the spread of infections. Washing hands before and after patient contact is critical for protecting both the client and healthcare personnel, and is a key component of standard precautions.

• Viral load: Monitoring viral load in clients with HIV provides information about the effectiveness of antiretroviral therapy and disease progression. It helps guide clinical decisions and assess risk for opportunistic infections.

• Surgical site: Post-operative clients are at risk for surgical site infections. Monitoring the surgical site ensures early detection of infection, redness, drainage, or delayed healing, which is crucial for a client with compromised immunity.

Rationale for incorrect choices

• Place the client in a negative-pressure airflow room: Negative-pressure rooms are required for airborne precautions, such as tuberculosis or measles, not for asymptomatic HIV. Using such rooms unnecessarily can strain resources and is not indicated in this scenario.

• Place client in a private room: While private rooms may be used for client comfort, standard precautions do not mandate isolation unless there is a specific infectious risk. HIV alone does not require a private room.

• Administer anti-fungal medications: There is no evidence of fungal infection in this asymptomatic client. Prophylactic antifungal therapy is not indicated and could cause unnecessary side effects.

• Contact precautions: Contact precautions are required for infections that can be transmitted via direct or indirect contact (e.g., MRSA, C. difficile). This client has no active infectious condition requiring contact isolation.

• Droplet precautions: Droplet precautions are used for respiratory infections that spread via large droplets (e.g., influenza, pertussis). This client is not symptomatic and does not require droplet precautions.

• Airborne precautions: Airborne precautions are reserved for infections transmitted via small airborne particles (e.g., tuberculosis, measles, varicella). Asymptomatic HIV is not airborne, so these precautions are unnecessary.

• Sputum production: Monitoring sputum is relevant for clients with respiratory infections or pulmonary concerns. This client has no respiratory symptoms and sputum monitoring is not indicated.

• Serum electrolytes: Routine electrolyte monitoring is not specifically related to infection control or HIV management in this stable post-operative client.

• Urine output: While important in certain contexts, urine output does not specifically assess infection risk or progression of HIV in this scenario.

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The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?

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