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 B
Explanation
a. Administer a sedative to the client:
Administering a sedative may temporarily calm the client, but it should not be the first-line intervention, especially without a physician's order. Sedatives carry risks and should only be used when other interventions have been considered and deemed ineffective or when the client's behavior poses an immediate danger to themselves or others.
b. Contact a family member to come and sit with the client: could indeed be a valid first step. If a family member is available and able to assist, they could potentially calm the client without the need for isolation and reducing disruptive behavior.However, if this is not feasible, then ensuring the client’s safety through temporary isolation with frequent checks might be necessary.
c. Place the client in a wheelchair with a lap tray:
Placing the client in a wheelchair with a lap tray may restrict their movement and potentially exacerbate agitation or aggression. It does not address the underlying reasons for the behavior and may not be an appropriate intervention for managing wandering behavior.
d. Keep the client in her room with the door closed:
Isolating a client in their room could be considered a form of restraint or isolation and should be used with caution.This should be used only after other less restrictive measures have been tried and deemed ineffective.
Correct Answer is A
Explanation
a. "I should encrypt personal health information when sending emails."
This statement indicates an understanding of the importance of protecting confidential information during electronic communication. Encrypting personal health information in emails adds an extra layer of security to prevent unauthorized access.
b. "I can use another nurse’s password as long as I log off after using the computer."
This statement is incorrect and demonstrates a lack of understanding of client confidentiality. Sharing passwords is a violation of security policies and compromises the confidentiality of client information. Each nurse should have their unique login credentials to ensure accountability and traceability.
c. "I should discard personal health information documents in the trash before leaving the unit."
This statement is incorrect. Discarding personal health information in an unsecured manner, such as in the regular trash, can lead to unauthorized access and a breach of confidentiality. Proper disposal methods, such as shredding or using secure disposal containers, should be followed to protect sensitive information.
d. "I can post the client’s vital signs in the client’s room."
This statement is incorrect. Posting client information, including vital signs, in a public area like the client's room violates confidentiality. Personal health information should be shared only with authorized individuals involved in the patient's care and through secure communication methods. Posting such information in a public space compromises the client's privacy.
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