- A 36-year-old client with Crohn's disease has a newly placed abdominal surgical drain and requires a sterile dressing change at the insertion site. The RN sets up a sterile field, but a family member steps close and reaches toward the supplies. Which action by the nurse is BEST to maintain sterility?
Answer: Ask the family member to step back and continue if the supplies were not touched
This question tests the maintenance of sterile technique and sterile field for drain dressing changes. Critical principles include preventing non-sterile individuals from approaching or touching the field. Asking the family member to step back maintains sterility by ensuring no contact occurs. Continuing, gloving them, or moving closer risks contamination. The foundational principle of sterile technique requires isolation from untrained persons. Proximity invites breaches. In practice, educate visitors on boundaries and enforce distance during sterile procedures.
- A 29-year-old client with spinal cord injury and urinary retention needs a Foley catheter insertion. The RN applies sterile drapes and begins to set up the sterile tray. Which observation indicates a breach in sterile technique?
Answer: The RN's sterile glove touches the bed rail while reaching for the drainage bag
This question tests the maintenance of sterile technique and sterile field for catheter insertion. Critical principles include preventing sterile items from touching non-sterile surfaces like bed rails. The sterile glove touching the bed rail breaches sterility through direct contamination. Placing lubricant properly, keeping supplies above waist, and maintaining view are correct. The foundational principle of sterile technique is isolation from non-sterile contact. Any touch contaminates. In practice, position supplies within easy reach to avoid extending over non-sterile areas.
- A 63-year-old client with chronic venous ulcers requires a sterile dressing change. After donning sterile gloves, the RN realizes the sterile scissors are missing from the sterile kit. Which action by the nurse maintains sterility?
Answer: Ask a coworker to drop sterile scissors onto the sterile field without reaching over the field
This question tests the maintenance of sterile technique and sterile field during a dressing change for a client with chronic venous ulcers. Critical principles of sterile technique include preventing contamination by ensuring only sterile items touch the sterile field and avoiding reaching over the field to minimize airborne contamination. The correct action is to ask a coworker to drop sterile scissors onto the sterile field without reaching over it, as this allows the addition of a needed sterile item without compromising the field's integrity through direct contact or unnecessary exposure. Option A breaches sterility because wiping clean scissors with alcohol only disinfects them but does not achieve sterilization; option C risks contaminating the sterile field by leaving it unattended and potentially introducing contaminants upon return; option D is ineffective and breaches sterility as glove fingertips are not designed for cutting and could tear, exposing nonsterile skin. The foundational principle of sterile technique is that a sterile object remains sterile only if it comes into contact with other sterile objects. Additionally, any nonsterile item introduced to the sterile field renders the entire field contaminated, necessitating a complete restart of the procedure. A key strategy for maintaining sterility in practice is to anticipate all needed supplies before opening the sterile kit and to have a nonsterile assistant available to provide additional items without compromising the field.
- A 33-year-old postpartum client with a third-degree perineal laceration has an order for sterile perineal wound dressing change. The RN prepares the sterile field and pours sterile normal saline into a sterile basin. Which observation indicates a breach in sterile technique?
Answer: The RN allows the saline bottle cap to rest on the sterile field with the inside facing up.
The breach is the RN allowing the saline bottle cap to rest on the sterile field. Even with the inside of the cap facing up, the cap's rim and outer surface are nonsterile, and any contact with the sterile drape contaminates the field. In sterile technique, a removed cap should be held in the hand or kept off the field, never placed on it. The other observations are proper technique. Holding the bottle 1 inch above the basin while pouring in a slow, steady stream keeps the bottle from touching the sterile basin and limits splash. Placing the basin in the center of the sterile field keeps it within the sterile area and away from the nonsterile outer border. Checking the expiration date and confirming the seal is intact before opening ensures the solution remains sterile. None of these indicate a breach; only the cap touching the sterile field does.
- A 76-year-old client with type 2 diabetes mellitus has a surgical wound with moderate drainage requiring a sterile dressing change. After opening the sterile dressing kit, the RN realizes the client's call light is out of reach and the client is anxious. Which action by the nurse maintains sterility?
Answer: Continue the dressing change and address the call light after the sterile dressing is applied
This question tests the maintenance of sterile technique and sterile field for wound dressing changes. Critical principles include never leaving a sterile field unattended and prioritizing completion over non-urgent interruptions. Continuing the dressing change and addressing the call light after maintains sterility by avoiding abandonment or unnecessary glove changes. Stepping away, delegating, or removing gloves risks contamination. The foundational principle of sterile technique requires constant supervision of the field. Interruptions should be minimized. In practice, prepare the environment beforehand to avoid disruptions during sterile procedures.
- A 45-year-old client is in the operating room for an open appendectomy with a history of obesity and hypertension. The circulating nurse observes the sterile team preparing for incision. Which observation indicates a breach in sterile technique?
Answer: A sterile team member turns their back to the sterile field while adjusting their mask
This question tests the maintenance of sterile technique and sterile field in the operating room. Critical principles include keeping the back to the sterile field avoided to prevent unseen contamination and maintaining constant vigilance. A sterile team member turning their back to the field breaches sterility by risking airborne or contact contamination without monitoring. Keeping hands above waist, draping outward, and circulating nurse staying outside are all correct practices. The foundational principle of sterile technique is constant visual monitoring to ensure no breaches occur. Any lapse in oversight can introduce pathogens. In practice, position yourself to always face the sterile field and avoid turning away during procedures.
- A 61-year-old client with poorly controlled diabetes and neuropathy has a deep foot wound requiring a sterile dressing change. During the procedure, the nurse accidentally brushes the sterile glove against the client's bed sheet. Which action by the nurse maintains sterility?
Answer: Remove the contaminated glove, perform hand hygiene, don a new sterile glove, and continue with sterile supplies
This question tests the maintenance of sterile technique and sterile field when contamination occurs during a procedure. The critical principles include recognizing contamination immediately and taking appropriate steps to restore sterility without compromising the entire procedure. Removing the contaminated glove, performing hand hygiene, donning a new sterile glove, and continuing with sterile supplies (Answer B) correctly addresses the contamination while maintaining the integrity of the remaining sterile field. Continuing despite contamination (A) risks infection, applying hand rub over gloves (C) doesn't restore sterility, and having unlicensed personnel hold sterile supplies (D) violates sterile technique. The foundational principle is that contaminated items must be immediately replaced while preserving uncontaminated portions of the sterile field. To maintain sterility in practice, always have extra sterile gloves readily available and act immediately when contamination occurs.
- A 68-year-old client with end-stage renal disease and hypertension is in the intensive care unit for sepsis and needs a central venous catheter insertion at the bedside. While assisting the provider, the nurse notes the client is coughing intermittently and the sterile drape is in place; the nurse also sees the provider's sterile glove brush against the bed rail. Which observation indicates a breach in sterile technique?
Answer: The provider's sterile glove touches the bed rail after donning sterile gloves
This question tests the maintenance of sterile technique and sterile field during a central venous catheter insertion. The critical principles of sterile technique include maintaining sterility of all items within the sterile field and preventing contamination from non-sterile surfaces. The provider's sterile glove touching the bed rail (Answer A) represents a direct breach of sterility because the bed rail is a non-sterile surface that contaminates the glove. Placing equipment before opening sterile supplies (B) is appropriate sequencing, client coughing while wearing a mask (C) provides protection, and performing hand hygiene (D) is an essential preparatory step. The foundational principle is that any contact between sterile items and non-sterile surfaces immediately contaminates the sterile item. To maintain sterility in practice, healthcare providers must be constantly aware of their movements and the boundaries between sterile and non-sterile areas.
- A 40-year-old client with a history of intravenous drug use is admitted with infective endocarditis and requires a central line insertion. During the procedure, the RN observes the sterile drape has a small tear near the edge. Which action by the nurse maintains sterility?
Answer: Replace the torn drape with a new sterile drape before proceeding
This question tests the maintenance of sterile technique and sterile field during central line insertion. Critical principles include using intact drapes to create a barrier, replacing any compromised ones. Replacing the torn drape maintains sterility by ensuring an unbroken barrier against contamination. Covering, ignoring, or compensating with antiseptic does not restore integrity. The foundational principle of sterile technique is that drapes must be impermeable and intact. Tears allow pathogen passage. In practice, inspect drapes before and during use, replacing immediately if damaged.
- A 56-year-old client with diabetes mellitus is in the operating room for an open reduction and internal fixation of a fractured ankle. During the procedure, the circulating nurse notes the sterile instrument table is set up and the scrub person is gowned and gloved. Which observation indicates a breach in sterile technique?
Answer: The circulating nurse reaches over the sterile instrument table to adjust the overhead light
This question tests the maintenance of sterile technique and sterile field in the operating room environment. The critical principles of sterile technique include avoiding any movement over the sterile field by non-sterile personnel and maintaining the integrity of the sterile zone. The circulating nurse reaching over the sterile instrument table (Answer B) breaches sterility because non-sterile personnel must never reach over a sterile field, as this risks contamination from shedding skin cells, lint, or other particles. Keeping hands above waist level (A), requesting supplies before incision (C), and positioning tables away from traffic (D) all demonstrate proper sterile technique. The foundational principle is that the area above a sterile field must remain free from non-sterile intrusions to prevent contamination by gravity. In practice, circulating nurses should always walk around sterile fields rather than reaching over them.
- A 45-year-old client with acute pancreatitis has a central venous catheter inserted for vasoactive medications. During an infection control audit, the RN observes a colleague changing the central line dressing; the insertion site has mild redness and the client reports tenderness. The nurse should QUESTION which sterile technique?
Answer: Applying the new sterile dressing while wearing the same clean gloves used to remove the old dressing
This question tests the maintenance of sterile technique and sterile field during central line dressing changes. The critical principles include using appropriate barriers between clean and sterile portions of the procedure and never using the same gloves for both contaminated and sterile tasks. Applying the new sterile dressing while wearing the same clean gloves used to remove the old dressing (Answer D) breaches sterility because gloves contaminated with the old dressing cannot be used for sterile dressing application. Removing old dressing with clean gloves (A), proper antisepsis technique (B), and placing supplies on a disinfected surface (C) all demonstrate appropriate technique. The foundational principle is that there must be a clear demarcation between dirty and clean portions of any procedure, requiring glove changes between tasks. In practice, always change gloves and perform hand hygiene between removing old dressings and applying new sterile dressings.
- A 57-year-old client with chronic venous insufficiency has a large leg ulcer requiring a sterile dressing change. The RN opens a sterile irrigation solution and prepares to pour it into a sterile container. Which action by the nurse maintains sterility?
Answer: Pour the solution into the sterile container without allowing the bottle lip to touch the container
This question tests the maintenance of sterile technique and sterile field for irrigation. Critical principles include pouring without contact between bottle and container to avoid contamination. Pouring without touching maintains sterility by preventing transfer of microbes from the bottle lip. Placing cap down contaminates, recapping saves non-sterile solution, wiping doesn't sterilize. The foundational principle of sterile technique is no contact between sterile and non-sterile edges. Proper pouring height ensures this. In practice, hold bottles at a distance and pour steadily to preserve sterility.
- A 73-year-old client with heart failure has a peripherally inserted central catheter placed and now requires a sterile dressing change due to lifting edges. The RN prepares the sterile field and removes the old dressing with clean gloves. Which action by the nurse maintains sterility when transitioning to the sterile portion of the procedure?
Answer: Apply sterile gloves after removing clean gloves and performing hand hygiene
This question tests the maintenance of sterile technique and sterile field for PICC dressing changes. Critical principles involve transitioning from clean to sterile phases with hand hygiene and new gloves. Applying sterile gloves after hygiene maintains sterility for handling supplies. Keeping clean gloves, using sanitizer over them, or delegating breaches protocol. The foundational principle of sterile technique separates clean removal from sterile application. Hygiene bridges this. In practice, remove old dressings with clean gloves, then hygienize before sterile gloving.
- A 66-year-old client with a history of coronary artery disease is in the operating room for a hip arthroplasty. The circulating nurse is monitoring sterile technique. Which action by the nurse is MOST important to maintain a sterile field during the procedure?
Answer: Remind non-scrubbed personnel to maintain at least 30 cm (12 in) distance from the sterile field
This question tests the maintenance of sterile technique and sterile field in the operating room. Critical principles involve maintaining distance for non-scrubbed personnel to prevent accidental contamination. Reminding to keep 12 inches distance is most important to safeguard the field from reach or airflow issues. Hands below waist increase risk, back table is sterile, and anesthesia should not adjust drapes. The foundational principle of sterile technique requires spatial separation. Distance minimizes breaches. In practice, enforce buffer zones around sterile areas during procedures.
- A 48-year-old client with obesity is undergoing a surgical procedure. The circulating nurse notes the scrub nurse's sterile gown becomes damp at the abdomen after leaning against the sterile table edge. Which observation indicates a breach in sterile technique?
Answer: A damp area is considered contaminated and the gown should be changed
This question tests the maintenance of sterile technique and sterile field in the operating room. Critical principles include recognizing that moisture strikes through gowns, rendering them contaminated. A damp area indicates a breach as it allows microbial penetration through the gown. Waist level doesn't negate dampness, visible blood isn't the only sign, and glove dryness is irrelevant. The foundational principle of sterile technique is that barriers must remain dry and intact. Moisture compromises this. In practice, change damp gowns immediately to restore sterility.
- A 79-year-old client with benign prostatic hyperplasia and acute urinary retention requires an indwelling urinary catheter insertion. During setup, the RN opens the sterile catheter kit on the bedside table and notices the outer wrapper touches the floor. Which action by the nurse maintains sterility?
Answer: Discard the kit and obtain a new sterile catheter kit before proceeding
This question tests the maintenance of sterile technique and sterile field during urinary catheter insertion. Critical principles include discarding any sterile item that contacts a non-sterile surface like the floor to prevent contamination. Discarding the kit and obtaining a new one maintains sterility as the outer wrapper's contact with the floor compromises the entire package. Continuing use or wiping ignores contamination risks, and delegating opening breaches protocol without addressing the issue. The foundational principle of sterile technique is that once contaminated, an item cannot be re-sterilized in a clinical setting. Contamination is assumed if packaging integrity is questioned. In practice, always err on the side of caution by replacing potentially contaminated supplies to ensure patient safety.
- A 77-year-old client with heart failure and chronic kidney disease has a surgical incision with a negative pressure wound therapy dressing that requires a sterile dressing change. During the change, the nurse notes the sterile kit is open and the client suddenly reaches toward the sterile field. Which action by the nurse maintains sterility?
Answer: Move the sterile field away, replace any contaminated sterile supplies, and re-establish the sterile field before continuing
This question tests the maintenance of sterile technique and sterile field when contamination is threatened. The critical principles include recognizing potential contamination and taking appropriate corrective actions to re-establish sterility. Moving the sterile field away, replacing contaminated supplies, and re-establishing the sterile field (Answer B) is the correct action because any threat to sterility requires complete re-establishment of the sterile field. Simply asking the client to stop (A) doesn't address potential contamination, covering with a clean towel (C) contaminates the field, and applying more antiseptic (D) doesn't address contaminated supplies. The foundational principle is that when sterility is questioned or compromised, the entire sterile field must be considered contaminated and re-established. In practice, always err on the side of caution and replace any supplies that may have been contaminated.
- A 56-year-old client is in the operating room for a cholecystectomy and has a history of asthma. The circulating nurse observes the sterile back table has been set up, but the room door is repeatedly opened by staff entering to ask questions. Which action by the nurse is BEST to maintain the sterile field?
Answer: Ask staff to minimize door openings and keep traffic in and out of the room to a minimum
To maintain a sterile field, the most effective action is to minimize door openings and restrict traffic because air currents from door movement and personnel entry are the leading cause of airborne contamination. Placing a clean sheet over the sterile back table does not stop airborne particles from settling on exposed instruments, and it does not reduce the turbulence created by staff entering and exiting. Asking the scrub nurse to turn away from the field when the door opens does not block air currents from carrying particles onto the table; it only changes the nurse's position and may even increase the risk of accidental contact. Increasing the room temperature does not reduce airborne contamination; warmer air produces stronger convection currents that can lift and disperse particles, and it ignores the underlying problem of traffic. Thus, limiting traffic is the best way to protect the sterile field.
- A 70-year-old client with a history of recurrent urinary tract infections requires a Foley catheter insertion. The RN is preparing the sterile field and notices the sterile catheter package is intact but the expiration date was 2 months ago. Which action by the nurse maintains sterility?
Answer: Discard the catheter and obtain an unexpired sterile catheter before proceeding
This question tests the maintenance of sterile technique and sterile field for catheter insertion. Critical principles include using only unexpired sterile items to ensure integrity and efficacy. Discarding the expired catheter and obtaining a new one maintains sterility as expiration compromises packaging. Using it, soaking, or documenting ignores risks. The foundational principle of sterile technique relies on manufacturer guarantees until expiration. Post-expiration assumes loss of sterility. In practice, always check dates before opening and replace expired items immediately.
- A 40-year-old client with multiple sclerosis is admitted for urinary retention and requires an indwelling urinary catheter. During preparation, the nurse opens a sterile catheterization kit on the bedside table. Which action by the nurse maintains sterility during Foley catheter insertion?
Answer: Keep the dominant hand sterile while using the non-dominant hand to separate the labia and maintain that position
This question tests the maintenance of sterile technique and sterile field during urinary catheter insertion. The critical principles include maintaining hand designation (one sterile, one clean) and avoiding cross-contamination during the procedure. Keeping the dominant hand sterile while using the non-dominant hand to separate and maintain the labia (Answer C) correctly maintains sterility by designating specific roles for each hand throughout the procedure. Placing the catheter tip down while adjusting equipment (A) contaminates the catheter, holding near the tip (B) risks contamination of the insertion portion, and using clean gloves throughout (D) fails to maintain the required sterility for catheter insertion. The foundational principle is that designated hand roles prevent cross-contamination between sterile and non-sterile areas. In practice, once hand roles are established during catheterization, they must be maintained throughout the entire procedure.
