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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Compromising:
Compromising involves finding a middle ground or mutually acceptable solution where both parties give up something to reach an agreement. It requires each party to make concessions to meet halfway and resolve the conflict. This approach aims to achieve a quick resolution by accommodating the needs and concerns of both sides to some extent.
b. Collaborating:
Collaborating involves working together cooperatively to find a solution that satisfies the interests and concerns of all parties involved. It requires open communication, active listening, and joint problem-solving to achieve a consensus and reach a win-win outcome. This approach values mutual respect, trust, and cooperation among team members, emphasizing shared decision-making and collective ownership of the resolution.
c. Cooperating:
Cooperating involves willingly assisting or supporting others to achieve a common goal or resolve a conflict. It emphasizes teamwork, mutual support, and shared efforts to address challenges or differences constructively. This approach promotes harmony, unity, and a supportive environment where individuals work together toward shared objectives.
d. Competing:
Competing, also known as forcing or dominating, involves pursuing one's own interests or preferences at the expense of others' concerns or viewpoints. It prioritizes assertiveness and control, with the goal of achieving one's desired outcome without considering the needs or perspectives of others. This approach can lead to conflict escalation, resentment, and strained relationships, as it disregards collaboration and mutual understanding in favor of imposing one's will.
Correct Answer is A
Explanation
A. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.
B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.
C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.
D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.
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