The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. Which action should the charge nurse take?
Plan to observe the secured IV site after the insertion procedure.
Remind the nurse to tape the gauze dressing securely in place.
Confirm that the nurse has gathered the necessary supplies.
Instruct the nurse to use a transparent dressing over the site.
The Correct Answer is D
A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.
B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.
C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.
D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. This meal option contains carbohydrates from the lasagna, salad dressing, and fruit, which can raise blood glucose levels.
B. Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake.
This meal option contains carbohydrates from the bun and angel food cake, which can raise blood glucose levels.
C. Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. This meal option contains significant amounts of carbohydrates from mashed potatoes and apple pie, which can raise blood glucose levels.
D. Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.
This meal option is lower in carbohydrates and contains healthier choices for a client with diabetes, helping to control blood glucose levels more effectively.
Correct Answer is D
Explanation
A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.
B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.
C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.
D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.
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