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.

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Correct Answer is B

Explanation

Choice A rationale:

Involving the client's parents in treatment decisions might not be appropriate if the client does not want them involved. Furthermore, the client's autonomy and wishes should be respected, and decisions about treatment should be primarily based on the client's preferences.

Choice B rationale:

This is the correct response. The nurse should respect the client's decision to discontinue chemotherapy and provide information about palliative care as an alternative option. Palliative care focuses on symptom management and improving the client's quality of life, aligning with the client's wishes to stop chemotherapy.

Choice C rationale:

Contacting the spiritual advisor is not directly related to the client's expressed desire to discontinue chemotherapy. While spiritual and emotional support are important, the primary concern here is addressing the client's medical decisions.

Choice D rationale:

Contacting the client's parents to discuss durable power of attorney is not appropriate if the client does not want them involved in the decision-making process. The client's autonomy and preferences should be respected, and they should be empowered to make their own medical decisions.

A. Remind the staff members that this is a breach of confidentiality. B. Discuss the issue with the nurse manager. C. Request that an administrative restriction be placed on the client's record access. D. Prepare a memo for the facility ethics committee.

Correct Answer is A

Explanation

Choice A rationale:

Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.

Choice B rationale:

Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.

Choice C rationale:

Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.

Choice D rationale:

Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.

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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

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