A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?
Withdraws the medication from the ampule using a subcutaneous needle
Breaks the top of the ampule using an antiseptic wipe
Disposes of the ampule by placing it in a sharp’s container
Performs 3 checks of the medication before administration
The Correct Answer is A
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.
Correct Answer is B
Explanation
Choice A Reason:
Escorting the nurses to the nurses' lounge to continue the discussion is incorrect. While removing the nurses from a public area to discuss the matter further might seem like a good idea, it does not address the underlying issue of unprofessional behavior and inappropriate discussion about patient care. The charge nurse should intervene to address the situation more formally.
Choice B Reason:
Contacting the house supervisor to mediate the conflict is correct. Contacting the house supervisor ensures that the issue is escalated appropriately and that a neutral party with authority can intervene to mediate the conflict. The house supervisor can help address the nurses' concerns while emphasizing the importance of professionalism and patient-centered care.
Choice C Reason:
Recommending that both nurses be terminated is incorrect. Termination should only be considered after a thorough investigation and due process. Jumping to termination as the first course of action is inappropriate and may not be warranted in this situation, especially without understanding the full context and reasons behind the nurses' behavior.
Choice D Reason:
Making arrangements to take over the client's care is incorrect. While ensuring continuity of care for the client is important, taking over the client's care without addressing the underlying issue of unprofessional behavior and inappropriate discussion about patient care does not address the root cause of the problem. It's important to address the behavior of the nurses through appropriate channels and ensure that they understand the importance of professionalism and patient confidentiality.
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