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 B
Explanation
a. "You must choose a member of your family to serve as your health care proxy":
This response is not accurate. While family members are often chosen as healthcare proxies, the client is not required to select a family member. The most important consideration is choosing someone who understands the client's healthcare wishes and is willing and able to advocate for them. The nurse should emphasize the importance of selecting a trusted individual, whether they are a family member or not.
b. "A health care proxy can make decisions for you when you are unable to do so":
This response is accurate. A healthcare proxy is a legal document that allows an individual to appoint someone else to make healthcare decisions on their behalf if they become unable to do so due to illness or incapacity. The nurse should explain the role of a healthcare proxy in advocating for the client's wishes and ensuring that their healthcare preferences are honored.
c. "You should appoint a health care proxy before undergoing an invasive procedure":
While it is advisable for clients to have advance directives, including a healthcare proxy, in place before undergoing any medical procedure, this response does not fully address the client's question. The timing of appointing a healthcare proxy should not be limited to specific medical procedures but should be based on the client's readiness to make such decisions and their recognition of the importance of having a designated advocate for their healthcare needs.
d. "It is necessary for an attorney to approve your health care proxy":
This response is not accurate. While it may be helpful to seek legal advice when creating advance directives, including a healthcare proxy, it is not a requirement for an attorney to approve the document. The client can typically complete a healthcare proxy form themselves, following the legal requirements of their jurisdiction. However, consulting with an attorney can provide additional guidance and ensure that the document is properly executed.
Correct Answer is D
Explanation
a. Compromising:
Compromising involves finding a middle ground or mutually acceptable solution where both parties give up something to reach an agreement. It requires each party to make concessions to meet halfway and resolve the conflict. This approach aims to achieve a quick resolution by accommodating the needs and concerns of both sides to some extent.
b. Collaborating:
Collaborating involves working together cooperatively to find a solution that satisfies the interests and concerns of all parties involved. It requires open communication, active listening, and joint problem-solving to achieve a consensus and reach a win-win outcome. This approach values mutual respect, trust, and cooperation among team members, emphasizing shared decision-making and collective ownership of the resolution.
c. Cooperating:
Cooperating involves willingly assisting or supporting others to achieve a common goal or resolve a conflict. It emphasizes teamwork, mutual support, and shared efforts to address challenges or differences constructively. This approach promotes harmony, unity, and a supportive environment where individuals work together toward shared objectives.
d. Competing:
Competing, also known as forcing or dominating, involves pursuing one's own interests or preferences at the expense of others' concerns or viewpoints. It prioritizes assertiveness and control, with the goal of achieving one's desired outcome without considering the needs or perspectives of others. This approach can lead to conflict escalation, resentment, and strained relationships, as it disregards collaboration and mutual understanding in favor of imposing one's will.
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