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. "If you have the procedure now, you won’t have to deal with pain and disability later."

This response dismisses the client's concerns about pain and focuses solely on the potential benefits of the surgery. It fails to address the client's apprehension and does not provide support or empathy. Furthermore, it oversimplifies the situation and may come across as dismissive of the client's feelings.

b. “I understand, and it’s not too late to change your mind.”

This response demonstrates empathy and validation of the client's concerns. It acknowledges the client's autonomy and gives them the option to reconsider without judgment or pressure. It encourages open communication between the nurse and the client, fostering a supportive environment.

c. “Why didn’t you discuss your concerns with your provider?”

This response may come across as accusatory or blaming, which can further distress the client. It does not offer immediate support or validation of the client's concerns. While discussing concerns with the provider is important, this response fails to address the client's immediate distress and need for reassurance.

d. “You’ll be fine. You’ll receive a prescription for pain medication.”

This response minimizes the client's concerns by reassurance without addressing the underlying issue. It also assumes that pain medication will resolve all concerns related to pain, which may not be the case for the client. Additionally, it overlooks the client's emotional needs and autonomy in decision-making.

A. Green B. Yellow C. Black D. Red

Correct Answer is C

Explanation

a. Green:

Green triage tags are typically used for "walking wounded" or patients with minor injuries who can wait longer for treatment. These patients are considered to have non-life-threatening injuries and can be managed after more critical patients have been stabilized.

b. Yellow:

Yellow triage tags are used for patients with moderate injuries who require medical attention but are not in immediate danger of death. These patients may have significant injuries that require timely treatment but do not have life-threatening conditions.

c. Black:

The black tag is used for patients who are not expected to survive due to severe injuries or critical conditions. In the case of full-thickness burns covering a large percentage of the body (such as 72%), the patient’s prognosis is poor, and immediate care resources should be allocated to those with a higher chance of survival.The black tag indicates that the patient’s injuries are incompatible with life, and comfort measures may be provided, but resuscitation efforts are not a priority.

d. Red:

Red triage tags are used for patients with life-threatening injuries who require immediate medical attention to survive. These patients have critical conditions that require rapid assessment, stabilization, and treatment to prevent further deterioration and improve outcomes.

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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

A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

Correct Answer is C

Explanation

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