The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

Give positive feedback to the PN and document the skill competency.

Explain to the PN that the sterile sponges are not needed for the procedure.

Remind the PN to wash his hands before applying the sterile gloves.

Ask the PN to remove the gloves and sponges and start over with a new set.

Answer and Explanation

The Correct Answer is D

Choice A reason: Giving positive feedback to the PN and documenting the skill competency is not the appropriate action to take. The PN did not demonstrate proper sterile technique, as he touched the outside of the sterile glove package and the sterile sponges with his bare hands, contaminating them.

Choice B reason: Explaining to the PN that the sterile sponges are not needed for the procedure is not the relevant action to take. The PN may have been following the instructions of the healthcare provider, who may have requested the sponges for the procedure. The issue is not the need for the sponges, but the way the PN handled them.

Choice C reason: Reminding the PN to wash his hands before applying the sterile gloves is not the sufficient action to take. Washing the hands is an important step in maintaining infection control, but it does not correct the mistake the PN made by touching the sterile items with his bare hands.

Choice D reason: Asking the PN to remove the gloves and sponges and start over with a new set is the best action to take. It ensures that the PN follows the correct sterile technique and does not compromise the safety of the client or the procedure. It also provides an opportunity for the charge nurse to teach the PN how to avoid contamination.

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Correct Answer is A

Explanation

Choice A reason: Using simulation activities is the most useful action for the nurse to include during the teaching session. It allows the clients to practice and apply their problem-solving skills in realistic and relevant scenarios. It also enhances their motivation, engagement, and feedback.

Choice B reason: Offering positive reinforcement is a helpful action for the nurse to include during the teaching session, but not the most useful one. It can increase the clients' confidence and self-efficacy, but it does not directly teach them how to solve problems.

Choice C reason: Incorporating verbal analogies is a creative action for the nurse to include during the teaching session, but not the most useful one. It can help the clients to understand complex or abstract concepts by relating them to familiar or simpler ones, but it does not necessarily improve their problem-solving skills.

Choice D reason: Providing physical demonstrations is a clear action for the nurse to include during the teaching session, but not the most useful one. It can show the clients how to perform a specific task or procedure, but it does not encourage them to think critically or independently.

A. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. B. Teach the client that the oral mucosa must remain dry to prevent aspiration. C. Turn the suction off while allowing the client to rinse his mouth with cool water. D. Instill 50 ml of normal saline solution into the tube and clamp the tube for one hour.

Correct Answer is A

Explanation

Choice A reason: Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.

Choice B reason: Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.

Choice C reason: Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.

Choice D reason: Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.

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The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

Nursing Test Bank

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Correct Answer is A

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