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 D
Explanation
Choice A rationale:
The National League for Nursing (NLN) focuses on nursing education standards and resources for nursing faculty. While it could provide useful insights, it's not the primary resource for policy creation related to procedures like catheter insertion.
Choice B rationale:
The American Academy of Nursing (AAN) is a professional organization that promotes leadership and education within nursing. While it might offer recommendations, it's not the primary resource for policy related to procedural changes in clinical settings.
Choice C rationale:
The Agency for Healthcare Research and Quality (AHRQ) is involved in research and quality improvement initiatives in healthcare. While it could provide evidence-based practices, it's not the primary source for policies specific to nursing procedures.
Choice D rationale:
The State Nurse Practice Act (NPA) outlines the scope of nursing practice within a particular state. It governs what nurses are allowed to do, including procedures like catheter insertion. The NPA ensures that nursing actions are within legal and regulatory bounds, making it the most relevant resource for creating a policy about catheter insertion.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
The client does not have transportation for discharge home. Rationale: While transportation is important for discharge planning, it is not the priority concern in this situation. The client's immediate needs and well-being take precedence over transportation concerns.
Choice B rationale:
The client refuses to attend physical therapy sessions. Rationale: The correct choice. After a hip surgery, physical therapy is crucial for preventing complications, promoting mobility, and ensuring optimal recovery. The refusal to attend these sessions could lead to delayed healing, increased risk of complications, and impaired functional outcomes. Addressing the client's resistance to therapy is a priority to ensure the best possible recovery.
Choice C rationale:
The client's home health nurse has not completed the home assessment. Rationale: While a home assessment is important for discharge planning, it is not the most immediate concern. The client's refusal to attend physical therapy could have more immediate and significant effects on their recovery and well-being.
Choice D rationale:
The client describes feelings of depression after family visits. Rationale: While addressing the client's emotional well-being is important, it is not the priority concern in this situation. The refusal to attend physical therapy sessions could have physical consequences that take precedence over the emotional aspect.
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