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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Check the client's medical record for the provider's prescription is the appropriate action to confirm whether the enema was indeed ordered and to ensure that the client’s concerns are addressed.

B. Inform the charge nurse that the client refused the enema might be premature without first verifying the order and addressing the client's concerns.

C. Explain to the client that the provider prescribed the procedure is not appropriate if you have not confirmed the order. It may be premature if the order is not documented.

D. Assure the client that enemas are commonly prescribed for constipation does not address the client’s specific concern about whether the enema was actually ordered.

A. Reassign the task to another nurse. B. Report the issue to the unit manager. C. Change the client's dressing. D. Verify the LPN knows how to do a dressing change.

Correct Answer is D

Explanation

A. Reassign the task to another nurse: While reassignment may be an option, it does not address the underlying issue. Ensuring the LPN has the knowledge and skill to complete the task is more effective in addressing both immediate and future concerns.

B. Report the issue to the unit manager: Reporting to the manager might be appropriate if the issue persists or reflects repeated non-compliance. However, verifying the LPN's competence and addressing the problem directly should be the first step.

C. Change the client’s dressing: While changing the dressing resolves the immediate client need, it does not address the issue of delegation or why the task was not completed. This approach bypasses the opportunity to assess and support the LPN.

D. Verify the LPN knows how to do a dressing change: Before taking further action, the charge nurse should determine why the task was not completed. If the LPN lacks the knowledge or skill to perform a dressing change, the nurse must address this gap and provide appropriate education or support to ensure client care is not compromised.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?

Correct Answer is A

Explanation

A charge nurse delegates to a licensed practical nurse (LPN) the task of changing a client's dressing. Several hours later the client reports the dressing has not been changed. Which of the following actions should the charge nurse take?

Correct Answer is D

Explanation

The charge nurse is planning to delegate client care tasks. Exhibits For each task identify the team member to which the nurse should delegate the task. Each task may be appropriate for more than 1 team member.

A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

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A nurse is caring for a client whose family member requests to view the client's medical record. Which of the following responses should the nurse make?

A nurse manager is preparing an inservice program for the nurses on the unit about the use of a new infusion pump. Which of the following teaching strategies is the most effective way to ensure that the staff can use the device correctly?

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.)

A charge nurse is delegating tasks to nursing personnel on a 10-bed medical-surgical nursing unit. Which of the following assignments is an example of overdelegation?

A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?