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 C

Explanation

a. "You can ask an AP to teach a simple task to a client."

While assistive personnel may assist with client education under the supervision of a licensed nurse, the primary responsibility for teaching tasks to clients usually rests with licensed healthcare providers.

b. "You should assign tasks you are unfamiliar with to an experienced AP."

Delegating tasks to assistive personnel should be based on their competency and the complexity of the task, not necessarily on the nurse's familiarity with it. It is essential to delegate tasks that the AP is trained and competent to perform.

c. "If you are unsure about an AP’s ability, observe them performing the task."

This is the correct statement. It emphasizes the importance of assessing an assistive personnel's competence by observing their performance before delegating tasks, especially if there is uncertainty about their abilities.

d. "The person who delegates a task is not held accountable for the outcome."

This statement is incorrect. The person delegating a task is ultimately accountable for ensuring that the task is performed correctly and safely. Delegation does not relieve the delegator of accountability.

A. Limited social support B. Decreased self-esteem C. Inadequate food supply D. Low pain tolerance

Correct Answer is C

Explanation

a. Limited social support:

Limited social support can impact the client's ability to manage their recovery and may increase the risk of complications or readmission. However, it may not be the most immediate concern if other issues pose a more significant risk to the client's health and recovery.

b. Decreased self-esteem:

Decreased self-esteem can affect the client's emotional well-being and may impact their motivation to engage in self-care activities. While important to address, it may not have an immediate impact on the client's physical recovery following CABG surgery.

c. Inadequate food supply:

Inadequate food supply can hinder the client's ability to meet their nutritional needs, which are essential for wound healing and overall recovery after surgery. This issue could potentially impact the client's physical recovery and should be addressed promptly.

d. Low pain tolerance:

Low pain tolerance can affect the client's ability to manage postoperative pain and may hinder their participation in activities necessary for recovery, such as mobility and respiratory exercises. Addressing pain management is crucial for promoting the client's comfort and facilitating recovery.

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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

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