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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Confine the fire by closing doors and windows. While confining the fire is important, the nurse's first priority should be ensuring the safety of the client. Closing doors and windows may help prevent the fire from spreading, but it does not address the immediate danger to the client.

Choice B rationale:

Activate the fire alarm system. Activating the fire alarm is a crucial step to alert other staff members, patients, and visitors about the fire. However, it is not the first action the nurse should take. Ensuring the safety of the client should be the top priority.

Choice C rationale:

Extinguish the fire if possible. Attempting to extinguish the fire can be dangerous for the nurse and may waste precious time. The nurse's safety and the client's safety should be the primary concern. Trying to put out the fire before ensuring the client's safety is not the best course of action.

Choice D rationale:

Rescue the client from immediate danger. This is the correct answer because the nurse's first priority in a fire emergency is to ensure the safety of the client. Rescuing the client from immediate danger should be done before any other actions are taken. The nurse should assess the situation, help the client to safety, and then notify others about the fire and activate the alarm system.

A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish remover or hair spray should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.

Correct Answer is ["D"]

Explanation

Choice A rationale:

Tying the straps of the restraints in a double knot is incorrect. This action can make it difficult to quickly release the restraints in case of an emergency. A single, quick-release knot is recommended to ensure the client's safety.

Choice B rationale:

Tying the restraints to the side rails is incorrect. Attaching restraints to the side rails can cause injury to the client and is not a proper restraint application method. Restraints should be tied to the bed frame, not the side rails, to prevent harm.

Choice C rationale:

Placing the padding of the restraints against the client's bony prominences is incorrect. While padding is important to prevent skin breakdown and pressure ulcers, the correct placement of the padding alone does not indicate a comprehensive understanding of proper restraint application.

Choice D rationale:

Inserting one finger between the client's wrist and the restraint is the correct action. This technique ensures that the restraints are not too tight, allowing for proper circulation and preventing injury to the client. The ability to insert one finger indicates that the restraints are snug but not constrictive, maintaining the client's safety and comfort.

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A nurse is preparing to open a sterile pack. The nurse has performed the task correctly when the nurse demonstrates what?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client's room and sees smoke coming from the client's trash can.Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is providing reinforcing discharge instructions to a client who has a prescription for oxygen use at home.Which of the following information should the nurse include? (Select all that apply.)

Correct Answer is ["D"]

Explanation

A nurse explains to a client with hypertension that diastolic pressure is a measurement of what?

A nurse delegates the application of wrist restraints for a client who is confused to an assistive personnel (AP) The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

397 mg = __ g. Convert the measurement. (Do not round. Enter only the number, no label) .

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

When the nurse is preparing a sterile field using the drape provided in a sterile pack, the nurse would only touch which part of the sterile drape?

A nurse is caring for a group of clients on an infectious disease unit. The nurse should wear an N95 respirator mask when caring for a client who has which of the following disorders?

When caring for a client, the nurse knows the best method to reduce healthcare-associated infections (HAIs) is to do what?

How often must you or an assistant check on a patient who is restrained?

A nurse is preparing to open a sterile pack.
The nurse has performed the task correctly when the nurse demonstrates what?