A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as demonstrating sterile technique?
The nurse places the sterile package with the top flap opening away from the body.
The nurse pinches the flap on the inside of the package first to open it.
The nurse reaches over the package to open the left flap.
The nurse pulls the last flap of the package away from the body.
The Correct Answer is A
Choice A rationale:
Placing the sterile package with the top flap opening away from the body is the correct choice. This technique helps maintain the sterility of the contents by preventing potential contamination from the nurse's body and clothing.
Choice B rationale:
Pinching the flap on the inside of the package first to open it is not a recommended sterile technique. It could potentially introduce contamination from the nurse's hand into the sterile field when pinching the inner flap.
Choice C rationale:
Reaching over the package to open the left flap is not the ideal technique. Reaching over the sterile field can introduce the risk of contamination, as the nurse's arm and body might come into contact with the sterile supplies.
Choice D rationale:
Pulling the last flap of the package away from the body is not the most effective technique. This action could potentially lead to the nurse's hand coming close to or over the sterile field, increasing the risk of contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Since the client speaks a different language than the nurse, involving an interpreter is crucial to ensure effective communication during the preoperative teaching. This will help the client fully understand the procedure, potential risks, and postoperative care instructions.
Choice B rationale:
A social worker primarily addresses psychosocial needs and resources. While they play an important role, their involvement wouldn't directly address the language barrier during the preoperative teaching.
Choice C rationale:
An occupational therapist assists with physical function and daily activities. While they might be involved postoperatively, their role is not as crucial for overcoming the language barrier during preoperative teaching.
Choice D rationale:
A spiritual advisor provides support based on religious or spiritual beliefs. While emotional and spiritual support are important, their involvement in this scenario doesn't address the language barrier and the need for accurate information during preoperative teaching.
Correct Answer is D
Explanation
Choice A rationale:
Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.
Choice B rationale:
Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.
Choice C rationale:
Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.
Choice D rationale:
Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.
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