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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Informing the staff member of her appraisal time for that day prior to change-of-shift report is not ideal as it may disrupt the shift handover process.

B. Scheduling the appraisal interview as early in the shift as possible might not be feasible or considerate, especially if it impacts patient care or the staff member's workflow.

C. Providing the staff member with a copy of the appraisal form in advance is best practice as it allows the staff member to prepare for the discussion and address any concerns or achievements.

D. Providing a chair directly across the desk for the staff member to sit in is not as important as preparing the staff member by sharing the appraisal criteria in advance.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

False Imprisonment: This refers to the unlawful restraint of an individual's freedom of movement. By applying wrist restraints without a clear and immediate order from a provider or without proper justification, the nurse could be restricting the client's freedom of movement inappropriately.

Applying wrist restraints to the client: This action is a key factor in the potential for false imprisonment. Restraints should be used only when necessary and with proper authorization and documentation, particularly in non-emergency situations.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 charge nurse is planning to conduct a performance appraisal of a staff member on her unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

An RN from the maternal-newborn unit is being floated to a medical-surgical unit. Which of the following clients should the charge nurse on the medical-surgical unit plan to assign to the RN?

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take?

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

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 charge nurse is discussing disaster response with nursing staff. Which of the following statements indicates an understanding of the Hospital Incident Command System (HICS)?

A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Exhibits Complete the following sentence by using the list of options. The nurse should instruct the newly licensed nurse to first dropdown then dropdown.

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)