A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
The nurse uses clean gloves when discontinuing a client's intravenous infusion.
The nurse uses the client's telephone number as one form of identification when administering medications to a client.
The nurse empties a client's drainable colostomy pouch when it is one-third full.
The Correct Answer is A
Rationale:
A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C. The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).
D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Performing blood glucose monitoring before breakfast is crucial for timely insulin administration and managing diabetes effectively.
B. Applying a condom catheter is important but can generally be done after more urgent tasks.
C. Delivering a clean urine specimen is important but less time-sensitive compared to blood glucose monitoring.
D. Feeding a client is important but may not be as urgent as tasks directly affecting medical management.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}
Explanation
Client 3: Collect and label specimen.
Assistive personnel- Assistive personnel can handle the collection and labeling of specimens, which is a routine task that does not require advanced clinical judgment.
Client 1: Perform prescribed procedure.
Practical Nurse- Insertion of a nasogastric tube is a procedure that requires clinical skills and knowledge, making it appropriate for a licensed practical nurse (LPN) to perform.
Client 3: Administer prescribed medication.
Practical Nurse- Administering medication is within the scope of practice for a practical nurse, as they are trained to handle medications and monitor their effects.
Client 4: Perform prescribed testing.
Assistive personnel- Testing such as using a glucometer for blood glucose monitoring can be performed by assistive personnel under the supervision of a registered nurse or practical nurse.
Client 4: Provide prescribed wound care.
Practical Nurse- Wound care, especially for a non-healing wound and cellulitis, requires clinical assessment and skills that a practical nurse is trained to provide.
Client 2: Transport client for diagnostic testing.
Assistive personnel- Transporting clients to diagnostic testing is a task that can be safely performed by assistive personnel.
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