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 A

Explanation

Choice A Reason:
Herpes simplex virus (HSV) requires contact precautions when there are active lesions. Wearing a cover gown helps prevent the transmission of the virus through direct contact with the client or contaminated surfaces, indicating proper understanding of isolation guidelines.

Choice B Reason:
Protective isolation (also known as reverse isolation) is used for clients who are immunocompromised, and they require a positive airflow room, not a negative airflow room. Positive airflow rooms help keep contaminants out, while negative airflow rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
An N95 respirator mask is required for airborne precautions (e.g., for tuberculosis, measles, or varicella) rather than contact precautions. Contact precautions generally involve wearing gloves and a gown, but an N95 mask is not necessary.

Choice D Reason:
For clients with Clostridium difficile (C. difficile) infection, soap and water must be used for hand hygiene, not alcohol-based hand cleansers. Alcohol-based hand sanitizers are not effective against C. difficile spores, so proper handwashing with soap and water is essential to prevent the spread of this infection.

A. Medicate the client with alprazolam. B. Reorient the client to his surroundings. C. Measure the client's vital signs. D. Offer reassurance to the family.

Correct Answer is C

Explanation

Choice A Reason:
Medicating the client with alprazolam, should not be the first action as it involves administering medication that could mask underlying issues and may not be appropriate without further assessment.
Choice B Reason:
Reorienting the client to his surroundings, is important for addressing confusion, but it should not be the first action until the nurse has ruled out any immediate physiological concerns.
Choice C Reason:
When a client presents with confusion and agitation after returning from an acute care facility, it's important for the nurse to prioritize assessing the client's physiological status by measuring vital signs. Changes in vital signs could indicate underlying medical issues such as infection, dehydration, or other physiological disturbances that may be contributing to the client's symptoms.
Choice D Reason:
Offering reassurance to the family, is important for providing support, but it should not be the first action as it does not directly address the client's immediate needs related to confusion and agitation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

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A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

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