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. Evaluate the results should occur after a resolution has been implemented, not at the initial stage.
B. Brainstorm solutions is a subsequent step after identifying and understanding the problem.
C. Implement a resolution should be done after identifying and brainstorming possible solutions.
D. Identify the problem is the crucial first step in conflict resolution. Understanding the nature of the conflict between the pharmacy and the staff nurses is necessary before moving on to developing solutions or implementing changes.
Correct Answer is B
Explanation
Rationale:
A. Reinforcing discharge teaching is less critical during a disaster and should be secondary to addressing immediate needs.
B. Focusing on life-threatening emergencies aligns with the priorities in a disaster situation, where resources are limited.
C. Stocking additional supplies should be managed based on current needs and priorities but is not as urgent as immediate patient care.
D. Focusing on ADLs is important but not the priority when dealing with life-threatening situations.
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