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 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.
Correct Answer is A
Explanation
Choice A rationale:
The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.
Choice B rationale:
The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.
Choice C rationale:
The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.
Choice D rationale:
The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.
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