A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

Gauze is used to clean the wound from the outside to the center.

The soiled dressing is placed on a nearby table.

Clean gloves are discarded after removing the old dressing.

Sterile supplies are opened prior to removing the old dressing.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Gauze is used to clean the wound from the outside to the center. This action does not demonstrate safe handling techniques. Wound cleaning should generally proceed from the least contaminated area to the most contaminated area, which is usually from the center of the wound outward, to avoid introducing microorganisms into the wound.
Choice B Reason:
The soiled dressing is placed on a nearby table. Placing the soiled dressing on a nearby table poses a risk of contamination to the surrounding environment and is not considered a safe practice. Soiled dressings should be properly disposed of in a designated biohazard waste container.
Choice C Reason:
This action demonstrates an understanding of infection control. Clean gloves should be discarded after removing the old dressing to prevent transferring any contaminants to the new dressing or sterile supplies.
Choice D Reason:
Sterile supplies should be opened only after the old dressing has been removed and the wound area has been cleaned.

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Correct Answer is D

Explanation

Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.

A. A client who is receiving heparin and has an aPTT of 34 seconds (30 to 40 seconds). B. A client who has type 1 diabetes mellitus and uses an insulin pump. C. A client who has orthostatic hypotension and is receiving IV fluids, D. A client who is at risk for pressure injuries and has an albumin level of 4.2 g/dL (3.5 to 5 g/dL). E. None F. None

Correct Answer is B

Explanation

A. The client’s aPTT is within the therapeutic range for heparin, so immediate interdisciplinary discussion is not required.

B. Clients using insulin pumps require coordination between the nurse, endocrinologist, and diabetes educator to ensure safe insulin administration and blood glucose management, making an interdisciplinary conference appropriate.

C. Orthostatic hypotension being managed with IV fluids can typically be addressed within routine nursing care without needing an interdisciplinary meeting.

D. The client’s albumin level is within normal limits, and risk for pressure injuries can be managed with standard nursing interventions without requiring a conference.

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A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

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