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 D

Explanation

Choice A rationale:

A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.

Choice B rationale:

A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.

Choice C rationale:

A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.

Choice D rationale:

Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.

A. The right to be treated with respect and dignity. B. The right to full access of the facility. C. The right to refuse their medications. D. The right to leave regardless of provider recommendations. E. The right to be fully informed of their health conditions.

Correct Answer is ["A","C","D","E"]

Explanation

The correct answers are choices A, C, D, and E:

Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.

In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.

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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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Correct Answer is D

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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