A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

The nurse places the sterile package with the top flap opening away from the body.

The nurse pinches the flap on the inside of the package first to open it.

The nurse reaches over the package to open the left flap.

The nurse pulls the last flap of the package away from the body.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.

Choice B rationale:

Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.

Choice C rationale:

Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.

Choice D rationale:

Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.

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Correct Answer is B

Explanation

Choice A rationale:

Determining the swallowing ability of a client who has had a stroke requires clinical judgment and assessment skills that fall within the scope of a registered nurse's practice. This task involves assessing potential risks and complications related to the client's condition.

Choice B rationale:

Providing an enteral feeding to a client who has Crohn's disease is within the scope of an LPN's practice. LPNs are trained to administer enteral feedings and manage stable clients with chronic conditions, such as Crohn's disease, under the supervision of a registered nurse.

Choice C rationale:

Developing a teaching plan for a client with a new diagnosis of type 2 diabetes mellitus involves comprehensive assessment, education, and planning. This task requires the expertise of a registered nurse, as it encompasses various aspects of disease management and requires tailored education based on individual client needs.

Choice D rationale:

Weighing a client who is 3 days postoperative following coronary artery bypass grafting involves monitoring for postoperative complications and assessing the client's stability. This task requires clinical judgment and the ability to recognize potential issues, making it more appropriate for a registered nurse to perform.

A. "I delegate tasks to personnel based on their job descriptions.” B. "Everyone working here has to care for clients who are incontinent.” C. "Let's talk about organizing the workflow so you care for fewer of these clients.” D. "Why do you not want to care for clients who are incontinent?”

Correct Answer is A

Explanation

The correct answer is choice A: "I delegate tasks to personnel based on their job descriptions."

Choice A rationale:

The response "I delegate tasks to personnel based on their job descriptions" is appropriate in this situation. Charge nurses are responsible for delegating tasks based on the scope of practice and job descriptions of the staff members. This response emphasizes the importance of adhering to established roles and responsibilities within the healthcare team.

Choice B rationale:

The statement "Everyone working here has to care for clients who are incontinent" may be true, but it does not address the specific concern raised by the assistive personnel (AP). It's important to provide a more focused response that addresses the AP's feelings and concerns.

Choice C rationale:

While discussing workflow organization to reduce the number of incontinent clients (Choice C) might be a potential solution, it doesn't directly address the AP's statement about fairness. The charge nurse's response should prioritize explaining the delegation process and addressing the AP's concerns about fairness.

Choice D rationale:

The response "Why do you not want to care for clients who are incontinent?" could be perceived as confrontational and defensive. It's essential to maintain a respectful and supportive tone when addressing staff concerns. This response does not effectively address the situation or provide a solution.

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A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is planning client care assignments for a unit. Which of the following tasks should the nurse assign to a licensed practical nurse (LPN)?

Correct Answer is B

Explanation

An assistive personnel (AP) tells a charge nurse that it is unfair that they have to take care of all the clients who are incontinent. Which of the following responses should the charge nurse make?

Correct Answer is A

Explanation

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