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 D
Explanation
Rationale:
A. A staff nurse typically does not function as the incident commander; this role is usually filled by someone with a leadership or administrative position in disaster planning.
B. An actual disaster cannot replace a drill because drills are designed to prepare staff for specific scenarios and ensure readiness.
C. A physician is not required to triage victims; this task can be performed by trained triage nurses or other designated personnel.
D. Regular disaster drills are essential for ensuring preparedness and assessing the effectiveness of disaster response plans.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Review the incident of disruptive behavior and discuss the principles of civility and respect.
Unit meeting
Rationale: The incident of disruptive behavior between nurses should be addressed in a unit meeting to foster a culture of respect and teamwork. Discussing this issue with the entire team will help reinforce appropriate behavior and conflict resolution.
Review mandatory nursing skills and competencies for nursing.
Unit meeting
Rationale: Mandatory nursing skills competencies are essential for ensuring that all staff meet the required standards. This should be reviewed during the unit meeting to ensure that all nurses are up to date and compliant with required competencies.
Meet to talk about mislabeling of laboratory specimens and discuss the policy and procedure for how to do it correctly.
Individual Team Member
Rationale: The issue of mislabeling specimens should be addressed directly with the specific individual (TJ, the AP) involved. It’s important to provide corrective feedback and retraining for the individual responsible for the issue.
Review near miss fall and fall precautions, bed position, rounding, and appropriate use of bed or chair alarms.
Unit meeting
Rationale: The near-miss fall incident involves issues that are relevant to the entire unit, such as bed position, use of bed alarms, and rounding practices. Discussing this in a unit meeting can help prevent future incidents by educating all staff on proper procedures.
Review central line infections rates and causes. Include review of proper care of central lines.
Unit meeting
Rationale: Reviewing central line infection rates and proper care is important for the entire team to ensure adherence to best practices and reduce infection rates. This is best addressed in a unit meeting to promote awareness and compliance among all staff.
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