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 A

Explanation

a. Prepare to administer antibiotics to the client.

This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.

b. Wear an N95 respirator mask while caring for the client.

While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.

c. Plan to administer an antiviral medication to the client.

Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.

d. Place a surgical mask on the client during transfer to the unit.

Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.

A. “A nurse can disclose information to a family member with the client’s permission.” B. “A nurse is responsible for informing clients about treatment options.” C. “A nurse can apply restraints on a PRN basis.” D. “A nurse can administer medications without consent to a client as part of a research study.”

Correct Answer is ["A"]

Explanation

A. Nurses are permitted to share a client’s information with family members only if the client grants permission. This aligns with the Health Insurance Portability and Accountability Act (HIPAA) and ensures the client’s right to privacy and confidentiality is upheld.

B.While nurses play a critical role in client education, it is the provider’s responsibility to explain treatment options, including risks, benefits, and alternatives. Nurses can reinforce this information and answer questions but are not the primary party responsible for obtaining informed consent.

C.Restraints must never be applied on a "PRN" (as needed) basis. They require a specific, time-limited order from a provider, and their use must be justified and continually reassessed. This ensures that client rights and safety are maintained.

D.Participation in a research study requires informed consent from the client. Administering medications without consent is a violation of the client’s rights and ethical standards, even in research settings.

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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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Explanation

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Correct Answer is ["A"]

Explanation

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