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

The correct answer is b. Social services.

Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.

Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.

Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.

Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.

A. Inform the client of the consequences of decreased cerebral circulation. B. Initiate a mental health consultation to determine why the client refuses the surgery. C. Discuss the client's concerns about having the surgery. D. Provide the client with information on additional treatment options.

Correct Answer is C

Explanation

Choice A rationale:

Informing the client of the consequences of decreased cerebral circulation is premature without understanding the client's specific reasons for refusing the surgery. Jumping to consequences might not address the underlying fears or concerns the client has, potentially leading to increased resistance or anxiety.

Choice B rationale:

Initiating a mental health consultation is a valuable step if the client's refusal appears to be influenced by psychological or emotional factors. However, before involving mental health professionals, it's important for the nurse to engage in a direct conversation with the client to explore their thoughts, fears, and reservations.

Choice C rationale:

Discussing the client's concerns about having the surgery is the most appropriate action in this scenario. Engaging in an open and nonjudgmental conversation allows the nurse to understand the client's perspective, provide information, clarify misconceptions, and address any fears or uncertainties. This approach respects the client's autonomy and promotes shared decision-making.

Choice D rationale:

Providing the client with information on additional treatment options might be premature if the client's main concern is related to the current recommended surgery. It's crucial to first address the client's specific reservations before exploring other treatment possibilities.

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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

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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