A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse?

Wears clean gloves to remove the soiled dressing

Uses slow, continuous pressure to flush the wound

Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed

Opens irrigation supplies before removing the soiled dressing

Answer and Explanation

The Correct Answer is D

a. Wears clean gloves to remove the soiled dressing: This action is appropriate. Wearing clean gloves helps maintain aseptic technique and prevents contamination of the wound during dressing removal.

b. Uses slow, continuous pressure to flush the wound: This action is appropriate. Using slow, continuous pressure helps ensure effective irrigation of the wound without causing trauma to the tissue.

c. Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed: This action is appropriate. Maintaining the appropriate distance ensures that the irrigation solution reaches the wound bed effectively without causing unnecessary trauma.

d. Opens irrigation supplies before removing the soiled dressing: This action is not appropriate. Opening irrigation supplies before removing the soiled dressing increases the risk of contamination. The nurse should first remove the soiled dressing using aseptic technique and then prepare the irrigation supplies.

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Correct Answer is B

Explanation

a. Advise him to complete less time-consuming tasks first:

This intervention may be helpful in prioritizing tasks and ensuring that essential care is provided in a timely manner. However, it does not address the underlying issue of difficulty focusing and may not address the root cause of the problem.

b. Recommend that he take time to plan at the beginning of his shift:

Planning at the beginning of the shift is essential for organizing tasks and prioritizing care. This intervention may help the newly licensed nurse improve their time management skills and focus by providing a structured approach to their work.

c. Offer to provide care for his clients while he takes a break:

While taking breaks is important for maintaining focus and preventing burnout, offering to provide care for his clients may not address the underlying issue of difficulty focusing and completing tasks. Additionally, taking over his tasks may not encourage the newly licensed nurse to develop the skills needed to improve his performance.

d. Ask other staff members to take over some of his tasks:

Asking other staff members to take over some of his tasks may provide temporary relief, but it does not address the underlying issue or help the newly licensed nurse develop the skills needed to improve his performance.

A. Close the documentation program on the computer B. Find out which staff member left the documentation program on the screen C. Tell the charge nurse that a visitor viewed a client’s protected health information D. Inform the visitor that client records are confidential

Correct Answer is A

Explanation

a. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

c. Tell the charge nurse that the visitor viewed a client’s protected health information:

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

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A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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