A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

Alert the infection control department

Discuss the issue with the AP

Reinforce facility protocols at the next staff meeting

Notify the unit manager about the incident

Answer and Explanation

The Correct Answer is B

a.   While alerting the infection control department is important, directly addressing the issue with the involved personnel should be the initial action.
b.   Discussing the issue with the assistive personnel (AP) allows for immediate clarification of the protocol and provides an opportunity to correct the behavior.
c.   Reinforcing facility protocols at a staff meeting may be necessary but should not be the first step when immediate action is required.
d.   Notifying the unit manager is important, but addressing the issue with the AP directly is the first step in resolving the situation and preventing future occurrences.

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Correct Answer is C

Explanation

A. Opened bottles of normal saline should be discarded after 24 hours to prevent contamination, even if stored in a refrigerator. Keeping them longer could increase the risk of infection, making this practice unsafe.

B. Sharps containers should be disposed of when they are three-quarters full, not completely full, to prevent needlestick injuries and ensure staff safety. This is a critical safety measure, not an appropriate cost-containment strategy.

C. Using clean gloves rather than sterile gloves for colostomy care is an appropriate cost-saving measure without compromising care. Clean gloves are sufficient for this procedure and help reduce unnecessary use of sterile supplies, which are more expensive.

D. Unused supplies from the bedside should not be returned to the supply stock due to infection control protocols. Once supplies have been taken to the bedside, they are considered contaminated and should be disposed of, not reused.

A. A client who is postoperative following a laminectomy 12 hour and is unable to void B. A client who is scheduled for a tubal ligation in 2 hours and is crying C. A client who has peripheral vascular disease and has an absent pulse in the right foot D. A client who has type 1 diabetes and needs the first dressing change for an ulcer

Correct Answer is C

Explanation

A. Postoperative urinary retention is common after surgery, especially within the first 12 hours. While this requires monitoring and possible intervention, it is not the highest priority.
B. Emotional distress before surgery is important to address, but it is not an immediate physiological concern requiring urgent intervention.
C. An absent pulse in the right foot indicates potential acute arterial occlusion, which is a medical emergency. This condition can lead to tissue ischemia and necrosis if not treated promptly. Immediate intervention is needed to restore circulation.
D. A dressing change for a diabetic ulcer is important for wound healing and infection prevention, but it does not take priority over a potential loss of circulation.

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A charge nurse witnesses assistive personnel failing to follow facility protocol when discarding contaminated lines. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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