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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
Role model a positive approach to the changes. Rationale: The correct choice. As a charge nurse, leading by example is crucial. Demonstrating a positive attitude toward the changes sets a tone for the unit and encourages staff members to approach the situation with an open mind.
Choice B rationale:
Redirect the conversation when staff members make negative comments about the changes. Rationale: The correct choice. Addressing negativity and redirecting the conversation helps maintain a constructive and respectful work environment. This approach allows for open dialogue while discouraging excessive negativity that can hinder the adaptation process.
Choice C rationale:
Encourage staff members who support the changes to discuss the issue with resistant staff. Rationale: While encouraging open communication is important, it might not be sufficient to address the resistance completely. The charge nurse should take a more active role in managing negativity and facilitating a positive transition.
Choice D rationale:
Suggest that resistant staff members transfer to a different unit. Rationale: Transferring staff members might not be a productive solution and can lead to further discord within the unit. It's important to address the issues within the current team before considering such drastic measures.
Choice E rationale:
Reprimand staff members who are resistant to the changes. Rationale: Adopting a punitive approach can escalate tensions and foster a negative work environment. It's better to focus on positive reinforcement and facilitating open conversations to manage resistance effectively.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not promise that a social worker will address the client's concerns, as this might not be accurate. While a social worker could be involved in the client's care, it's not their sole responsibility to address all concerns. The primary role of a social worker might be to provide emotional support and assistance with psychosocial issues.
Choice B rationale:
Suggesting that the client should plan to go to a skilled nursing facility after discharge might not be appropriate unless it's medically necessary. Terminal illness often requires a focus on palliative and hospice care rather than transferring to another care facility.
Choice C rationale:
This is the correct choice. The case manager plays a key role in coordinating the various resources and services the client will need after discharge. They ensure a smooth transition from the hospital to home, including arranging for home health care, medical equipment, and any other necessary services.
Choice D rationale:
Telling the client that they will need hospice care until they feel stronger is not appropriate. Hospice care is specifically for individuals with terminal illnesses who have a limited life expectancy. It is not about getting stronger but about providing comfort and support during the end-of-life period.
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