A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

Gauze is used to clean the wound from the outside to the center.

The soiled dressing is placed on a nearby table.

Clean gloves are discarded after removing the old dressing.

Sterile supplies are opened prior to removing the old dressing.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Gauze is used to clean the wound from the outside to the center. This action does not demonstrate safe handling techniques. Wound cleaning should generally proceed from the least contaminated area to the most contaminated area, which is usually from the center of the wound outward, to avoid introducing microorganisms into the wound.
Choice B Reason:
The soiled dressing is placed on a nearby table. Placing the soiled dressing on a nearby table poses a risk of contamination to the surrounding environment and is not considered a safe practice. Soiled dressings should be properly disposed of in a designated biohazard waste container.
Choice C Reason:
This action demonstrates an understanding of infection control. Clean gloves should be discarded after removing the old dressing to prevent transferring any contaminants to the new dressing or sterile supplies.
Choice D Reason:
Sterile supplies should be opened only after the old dressing has been removed and the wound area has been cleaned.

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Correct Answer is D

Explanation

Choice A Reason:
Reinforcing the potential consequences of not having advance directives on record is important, but the immediate priority is to ensure that the missing documentation is obtained.
Choice B Reason:
Reminding nurses to obtain advance directive information during the admission process is a proactive approach to preventing future instances of missing documentation. However, the priority now is to address the current gap in documentation for clients already admitted.
Choice C Reason:
Meeting with nursing staff to review the policy regarding advance directives can provide clarification and reinforcement of expectations, but again, the immediate priority is to address the missing documentation for current clients.
Choice D Reason:
Asking nurses who are caring for clients without this information in the medical record to obtain it. The priority action for the nurse manager is to ensure that advance directives, which are critical documents outlining a patient's wishes regarding medical treatment, are obtained for clients who currently lack documentation. This ensures that patients' preferences and choices regarding their care are respected, especially in critical situations.

A. Demonstrate the proper client transfer technique for the AP. B. Instruct the AP to request assistance when unsure about a task. C. Refer the AP to the facility procedure manual. D. Help the AP assist the client with the transfer.

Correct Answer is D

Explanation

Choice A Reason:
Demonstrating the proper client transfer technique for the AP, could be beneficial after ensuring the immediate safety of the client. However, providing immediate assistance to the client is the priority.
Choice B Reason:
Instructing the AP to request assistance when unsure about a task, is important for promoting a culture of safety and collaboration. However, in this scenario, the immediate focus is on assisting the client.
Choice C Reason:
Referring the AP to the facility procedure manual, may be helpful for providing additional guidance and education on proper techniques. However, in the moment, the nurse manager should prioritize immediate action to assist the client.
Choice D Reason:
Helping the AP assist the client with the transfer is correct. When a nurse manager observes an assistive personnel (AP) incorrectly performing a task such as transferring a client, the first priority is ensuring the safety and well-being of the client. Therefore, the nurse manager should intervene immediately to provide assistance and ensure that the client is transferred safely.

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A charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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