Which infection control actions would the nurse include in the use of standard precautions?

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: Collect patient information

The first step in the nursing process is to collect patient information, also known as the assessment phase. During this phase, the nurse gathers comprehensive data about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s needs and planning appropriate care.

Choice B: Identify any clinical problems

After collecting patient information, the next step is to identify any clinical problems, also known as the diagnosis phase. In this phase, the nurse analyzes the assessment data to determine the patient’s health issues or potential risks. This step involves critical thinking and clinical judgment to prioritize the patient’s problems and develop a nursing diagnosis.

Choice C: Decide a plan of action

The third step is to decide a plan of action, also known as the planning phase. During this phase, the nurse sets measurable and achievable goals for the patient’s care based on the identified clinical problems. The nurse also develops specific interventions to address these problems and achieve the desired outcomes. This plan serves as a guide for the subsequent implementation phase.

Choice D: Carry out the plan

The fourth step is to carry out the plan, also known as the implementation phase. In this phase, the nurse executes the planned interventions to address the patient’s clinical problems. This may involve administering medications, providing treatments, educating the patient and family, and coordinating care with other healthcare professionals. The nurse continuously monitors the patient’s response to the interventions and makes adjustments as needed.

Choice E: Determine whether the plan was effective

The final step is to determine whether the plan was effective, also known as the evaluation phase. During this phase, the nurse assesses the patient’s progress toward the established goals and evaluates the effectiveness of the interventions. If the desired outcomes are not achieved, the nurse may need to revise the plan and implement new strategies. This ongoing evaluation ensures that the patient’s care is continuously improved and optimized.