A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

Open the top flap of the sterile package towards the body.

Maintain a 1.25 cm (0.5 in) border around the edges of the sterile field.

Pick up the first sterile glove by grasping the folded cuff edge.

Remove soiled dressings using sterile gloves.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.

Choice A rationale:

Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.

Choice B rationale:

Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.

Choice C rationale:

Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.

Choice D rationale:

Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. "The client who had abdominal surgery 3 days ago is reporting feeling constipated.” B. "The client who had the hip replacement reports pain as 4 on a scale of 0 to 10.” C. "The client who had an indwelling urinary catheter removed 8 hr ago reports an inability to void.” D. "The client who is scheduled for discharge today states they are ready to sign their paperwork.”

Correct Answer is C

Explanation

Choice A rationale:

The client who had abdominal surgery 3 days ago reporting feeling constipated is an important assessment, but an inability to void after indwelling urinary catheter removal takes precedence due to the risk of urinary retention and potential complications such as bladder distention.

Choice B rationale:

The client who had a hip replacement reporting pain as 4 on a scale of 0 to 10 requires assessment and intervention, but an inability to void is a higher priority concern due to the potential impact on renal function and the urinary system.

Choice C rationale:

The client who had an indwelling urinary catheter removed 8 hours ago reporting an inability to void is the correct choice. This situation raises concerns about urinary retention, which can lead to serious complications such as bladder distention, urinary tract infections, and potential damage to the urinary system.

Choice D rationale:

The client scheduled for discharge today expressing readiness to sign paperwork is not an urgent concern compared to the other options. While discharge planning is important, addressing potential physiological issues takes precedence over administrative tasks.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

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

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

Correct Answer is C

Explanation

A case manager is planning an interprofessional conference for a client who is 3 days postoperative following an open reduction and internal fixation of the right hip. Which of the following concerns is the priority for discussion at the conference?

A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?

A nurse on a medical-surgical unit is caring for a client transferred from another department. The nurse should verify that the client has given informed consent prior to which of the following procedures?

A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?

A nurse is caring for a client who is scheduled for outpatient surgery. Which of the following actions should the nurse take to verify the client gave informed consent?

A nurse is assigning care for four clients. Which of the following tasks should the nurse plan to delegate to an assistive personnel (AP)?

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

A nurse manager finds that there has been an increase in urinary tract infections on the unit. To address this problem, which of the following actions should the nurse manager take first?