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 C
Rationale:
A. Opening a sterile tray flap toward the body can be incorrect practice, but it is a minor procedural issue that does not necessarily pose an immediate risk.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C. Using a telephone number as identification is not acceptable; proper identification should include at least two identifiers like name and 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. Cooperating involves finding a solution that satisfies both parties, as seen in allowing the nurses to go to lunch together while managing their clients.
B. Compromising would involve both parties giving up something to reach a middle ground, which is not exactly what is described.
C. Avoiding would mean not addressing the conflict directly, which is not the case here.
D. Competing involves asserting one’s own position at the expense of others, which does not align with the actions described.
Correct Answer is A
Explanation
Rationale:
A. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.
B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.
C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.
D. Complete an incident report might be premature without understanding the reason behind the refusal.
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