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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a. MS 10 mg IV every 4 prn for pain

This choice is incorrect because it lacks clarity and proper formatting. "MS" could be misunderstood as "morphine sulfate," but it's not specified. Additionally, "every 4 prn for pain" is not a standard way to write a prescription. It should indicate the frequency (e.g., every 4 hours) and the indication for administration (e.g., prn for pain).

b. Morphine sulfate 10 mg IV q 4 hr IV prn for pain

This choice is the correct transcription of the prescription. It clearly states the medication (morphine sulfate), the dosage (10 mg), the route (IV), the frequency (every 4 hours), and the indication for administration (prn for pain).

c. MSO4 10 mg IVP q 4 prn for pain

This choice is incorrect due to the use of abbreviations that may not be universally understood. While "MSO4" likely stands for morphine sulfate, it's preferable to write it out completely to avoid confusion. Additionally, "q 4" is not clear and should be written as "every 4 hours."

d. Morphine sulfate 10.0 mg every 4 hours IV prn for pain

This choice is incorrect because it specifies the dosage with unnecessary precision (10.0 mg instead of 10 mg). While this level of precision is not typically required in medication prescriptions, it doesn't make the prescription incorrect per se. However, it's not the most common or standard way to write medication orders.

A. Continue the medication dosages that relieve the client’s pain B. Contact the provider about replacing the opioid with an NSAID C. Administer the benzodiazepine but withhold the opioid D. Withhold the benzodiazepine but continue the opioid

Correct Answer is A

Explanation

A. Continue the medication dosages that relieve the client’s pain:
Opioids and benzodiazepines are commonly used for pain and anxiety management in terminally ill patients. Somnolence is an expected side effect and does not necessarily warrant withholding medication unless the client shows signs of respiratory depression.

B. Contact the provider about replacing the opioid with an NSAID: NSAIDs are not sufficient for severe pain in terminal illness. Opioids are the gold standard for palliative pain management, and switching to an NSAID would likely lead to uncontrolled pain and unnecessary suffering.

C. Administer the benzodiazepine but withhold the opioid: This would leave the client in severe pain, which is unethical in hospice care. Pain relief should not be withheld solely due to sedation.

D. Withhold the benzodiazepine but continue the opioid: Benzodiazepines are often used to relieve anxiety, dyspnea, and agitation in end-of-life care. Withholding it could cause increased distress for the client. Instead of discontinuing the medication, the nurse should monitor for respiratory depression and adjust doses only if necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a verbal prescription from the provider for a client who is having increased pain. The nurse should transcribe which of the following prescription in the client’s medical record?

Correct Answer is B

Explanation

A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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?

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