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A nurse is setting up a sterile field in a client's room. Which of the following actions should the nurse take?
- A. Placing a sterile instrument within 1.3 cm (0.5 in) of the edge of the sterile field
- B. Opening the top flap of the sterile tray package away from their body
- C. Dropping sterile objects onto the field from a height of 5 cm (2 in)
- D. Placing the cap of a sterile solution on a clean surface with the inside facing down
Correct Answer: B
Rationale: Opening the flap away maintains sterility by keeping the nurse's body out of the field.
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A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse plan to take?
- A. Cleanse the wound with cotton balls.
- B. Use a 10-mL syringe filled with cleansing solution.
- C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound.
- D. Dry the wound bed with gauze squares.
Correct Answer: C
Rationale: This technique ensures effective irrigation without damaging tissue.
A nurse is reinforcing teaching with a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
- A. I need to create advance directives so that I can donate my organs.
- B. I can name my sibling as my designee in my durable power of attorney for health care.
- C. My advance directives can be enforced once my attorney approves them.
- D. A family member will need to witness my signature on my living will.
Correct Answer: B
Rationale: Naming a designee is a key component of a durable power of attorney.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client's room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?
- A. Administer a sedative medication to the client.
- B. Have the client sign an against medical advice form.
- C. Tell the client that the surgeon will prescribe restraints if they try to leave.
- D. Explain to the client that they cannot leave until the surgeon discharges them.
Correct Answer: B
Rationale: An AMA form documents the client's informed decision to leave against advice.
A nurse is caring for a client who requires a sterile dressing change. The nurse should recognize that the surgical field has been contaminated if which of the following actions occur?
- A. A pair of sterile forceps is allowed to rest in a container of sterile water on the field.
- B. The sterile solution is poured with the bottle held over the field.
- C. Unnecessary sterile items are placed on the field.
- D. The handle of a pair of sterile scissors is resting 5 cm (2 in) from the field's edge.
Correct Answer: B
Rationale: Pouring over the field risks contamination from the bottle.