A charge nurse is observing a newly licensed nurse use aseptic technique when irrigating a client’s open abdominal wound. The charge nurse should intervene for which of the following actions by the newly license nurse?
Wears clean gloves to remove the soiled dressing
Uses slow, continuous pressure to flush the wound
Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed
Opens irrigation supplies before removing the soiled dressing
The Correct Answer is D
a. Wears clean gloves to remove the soiled dressing: This action is appropriate. Wearing clean gloves helps maintain aseptic technique and prevents contamination of the wound during dressing removal.
b. Uses slow, continuous pressure to flush the wound: This action is appropriate. Using slow, continuous pressure helps ensure effective irrigation of the wound without causing trauma to the tissue.
c. Places the syringe tip with angiocatheter 2.5 cm (1 in) above the open wound bed: This action is appropriate. Maintaining the appropriate distance ensures that the irrigation solution reaches the wound bed effectively without causing unnecessary trauma.
d. Opens irrigation supplies before removing the soiled dressing: This action is not appropriate. Opening irrigation supplies before removing the soiled dressing increases the risk of contamination. The nurse should first remove the soiled dressing using aseptic technique and then prepare the irrigation supplies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D"]
No explanation
Correct Answer is C
Explanation
a. Review current literature regarding client falls:
This option involves conducting a review of existing research and literature on client falls. Reviewing current literature can provide valuable insights into evidence-based practices and interventions for fall prevention. However, conducting a literature review typically follows problem identification and is part of the process of developing an evidence-based approach to addressing the issue.
b. Implement a fall prevention plan:
Implementing a fall prevention plan involves putting in place strategies and interventions aimed at reducing the risk of falls among clients. While implementing a fall prevention plan is an essential step in addressing the issue, it should be based on a thorough assessment of clients at risk for falls (which comes before planning interventions) to ensure that interventions are targeted and effective.
c. Identify clients who are at risk for falls:
This is the most appropriate first step in the quality improvement process. Identifying clients who are at risk for falls allows healthcare providers to focus interventions on those who are most vulnerable. It involves conducting comprehensive assessments, considering factors such as age, mobility, cognitive status, medications, and history of falls, to determine individual risk levels.
d. Notify staff of the increased fall rate:
While communication with staff about the increased fall rate is important for raising awareness and promoting a culture of safety, it should not be the first action taken in the quality improvement process. Before notifying staff, it's essential to identify clients at risk for falls and develop targeted interventions to address the issue effectively.
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