A nurse is preparing to open a sterile pack.
The nurse has performed the task correctly when the nurse demonstrates what?
Places the pack on a clean surface.
Turns the pack so that the first flap faces the nurse's body.
Opens the right-side flap first.
Touches only the inner surface of the inner wrapper.
The Correct Answer is B
Choice A rationale:
Providing the AP with the appropriate PPE (Choice A) is a good immediate action, but it does not address the issue comprehensively. It is crucial to report the incident to the higher authorities to ensure that appropriate measures are taken to prevent similar occurrences in the future.
Choice B rationale:
Notifying the charge nurse about the AP's lack of PPE (Choice B) is the most appropriate action in this situation. The charge nurse is responsible for overseeing the staff and ensuring compliance with safety protocols. Reporting the incident to the charge nurse allows for appropriate disciplinary action, additional training, or reminders about infection control procedures to prevent future violations.
Choice C rationale:
Volunteering to provide an in-service about infection control (Choice C) is a positive initiative, but it might not address the immediate issue at hand. While education is essential, the pressing matter is the AP's violation of infection control protocols, which needs to be reported promptly to the charge nurse.
Choice D rationale:
Speaking with the AP before leaving the shift about the appropriate protocol (Choice D) is insufficient on its own. While educating the AP about the correct protocols is essential, it should not replace reporting the incident to the charge nurse. Reporting ensures that appropriate actions are taken to maintain a safe environment for both healthcare workers and patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Pulse pressure is the difference between systolic and diastolic blood pressure and is not related to changing positions or the symptoms described in the scenario.
Choice B rationale:
Essential hypertension is a chronic medical condition characterized by elevated blood pressure levels persistently exceeding 140/90 mmHg. It is not directly related to positional changes or postural hypotension symptoms.
Choice C rationale:
Postural (orthostatic) hypotension occurs when a person experiences a sudden drop in blood pressure upon standing up from a sitting or lying position. This drop in blood pressure can lead to symptoms such as dizziness, lightheadedness, and fainting. Slowly changing positions is essential in managing postural hypotension because abrupt movements can worsen these symptoms. Educating the client about the importance of gradual position changes is crucial in preventing or minimizing postural hypotension-related symptoms.
Choice D rationale:
Pre-hypertension refers to blood pressure levels that are higher than normal but not high enough to be diagnosed as hypertension. It does not directly relate to the symptoms described in the scenario.
Correct Answer is ["A"]
Explanation
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
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