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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL is correct. This client has multiple risk factors for developing pressure ulcers, including a low albumin level. An interdisciplinary conference would be beneficial to involve various healthcare professionals, such as wound care specialists, dietitians, and physical therapists, to develop a comprehensive plan of care to prevent and manage pressure ulcers.
Choice B Reason:
A client who has Type 1 diabetes and uses an insulin pump is incorrect. While managing Type 1 diabetes requires coordination among healthcare providers, the use of an insulin pump alone may not necessitate an interdisciplinary conference unless there are specific concerns or issues that require input from multiple disciplines.
Choice C Reason:
A client who is receiving heparin and has an aPTT of 34 seconds is incorrect. Monitoring heparin therapy and adjusting doses based on laboratory values such as activated partial thromboplastin time (aPTT) is typically within the purview of the nursing and medical team. An interdisciplinary conference may not be necessary unless there are complications or concerns that require input from other healthcare professionals.
Choice D Reason:
A client who has orthostatic hypotension and is receiving IV fluids is incorrect. Orthostatic hypotension and IV fluid management are often managed primarily by the nursing and medical team. While input from other disciplines may be valuable in certain cases, it may not warrant scheduling an interdisciplinary conference unless there are specific complexities or challenges that require input from multiple disciplines.
Correct Answer is D
Explanation
Choice A Reason:
Fidelity is inappropriate. Fidelity refers to the obligation to fulfill commitments and responsibilities. While important in maintaining trust and professional relationships, fidelity may not directly apply to the situation described.
Choice B Reason:
Nonmaleficence is inappropriate. Nonmaleficence is the principle of doing no harm. In this situation, ensuring the safety and well-being of the client is paramount, and failing to use a gait belt could potentially lead to harm. However, the primary issue in this scenario is the accuracy and completeness of the incident report rather than the act of causing harm.
Choice C Reason:
Beneficence is inappropriate. Beneficence is the principle of doing good and acting in the best interest of the client. While ensuring the use of a gait belt aligns with promoting the client's safety and well-being, the primary concern in this scenario is the integrity and honesty in reporting the incident accurately.
Choice D Reason:
Veracity is appropriate. Veracity refers to truthfulness and honesty. In this situation, the charge nurse should ensure that the incident report accurately reflects the circumstances of the fall, including the absence of the gait belt. Being truthful and transparent in reporting incidents is essential for maintaining trust, promoting accountability, and improving patient safety.
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