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. "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.

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 on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?

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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