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. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.
B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.
C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.
D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.
Correct Answer is A
Explanation
Rationale:
A. Keeping an appointment with a client demonstrates fidelity by honoring commitments and ensuring reliability in care.
B. Allowing a new mother to hold her stillborn infant is compassionate care but relates more to the ethical principle of beneficence.
C. Confirming that a client going for surgery has signed a consent form is related to the principle of autonomy and informed consent.
D. Refusing to disclose information about a client to the media is related to confidentiality, not fidelity.
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