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

A. Nonmaleficence: By completing a critical care and emergency nursing course before transferring to the ICU, the nurse is ensuring they are adequately prepared to care for critically ill clients. This action minimizes the risk of harm caused by a lack of knowledge or skill, demonstrating adherence to the principle of nonmaleficence.

B. Veracity: Veracity refers to truthfulness and honesty in interactions with clients and colleagues. While important, this scenario does not focus on providing truthful information.

C. Autonomy: Autonomy refers to respecting a client's right to make decisions about their care. This scenario does not involve supporting or promoting client decision-making.

D. Fidelity: Fidelity refers to being faithful to commitments and promises made to clients or the profession. While the nurse is demonstrating professional responsibility, this scenario aligns more closely with nonmaleficence than fidelity.

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" D. "I am at a loss for words. I always do my best to give good care to my clients."

Correct Answer is C

Explanation

Rationale:

A. "What do you have against me? It must be something or you wouldn't be criticizing my care." is defensive and confrontational, which is not appropriate for assertive communication.

B. "You shouldn't make accusations. Your nursing care doesn't always set a good example." is also defensive and shifts the focus away from addressing the concern directly.

C. "I feel as though I met the standard of care. Would you tell me more about your concerns?" is an assertive response that acknowledges the concern and seeks constructive feedback.

D. "I am at a loss for words. I always do my best to give good care to my clients." is not assertive as it does not address the concern directly or invite constructive discussion.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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