A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?
Making a clinical decision in the patient's best interest.
Making a clinical decision based on previous shift assessments.
Making an ethical clinical decision
Making an informed clinical decision
The Correct Answer is B
A. Making a clinical decision in the patient's best interest: Making decisions in the patient’s best interest is an essential part of nursing practice and demonstrates good clinical judgment.
B. Making a clinical decision based on previous shift assessments. Nursing assessments should be conducted for each shift, as a patient’s condition can change rapidly. Relying on previous assessments without reassessing can lead to missed changes in the patient’s status, potentially causing harm.
C. Making an ethical clinical decision. Ethical decision-making is an integral part of nursing practice and aligns with professional standards. There is no need for intervention if the decision is ethical.
D. Making an informed clinical decision. Informed clinical decision-making is based on current patient data, clinical guidelines, and critical thinking. This is a correct approach to nursing care and does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Call the health care provider, a blockage is present in the tubing: A sudden decrease in drainage can indicate a blockage in the tubing, which could lead to fluid buildup and infection. The provider should be notified so that interventions can be taken (e.g., irrigation, assessment for clot formation).
B. Remove the drain, a drain is no longer needed: The nurse should not remove the drain without a provider’s order. A decrease in drainage does not necessarily mean the wound has healed.
C. Do nothing as long as the evacuator is compressed. Even if the evacuator is compressed, a sudden decrease in drainage is abnormal and requires further investigation. Ignoring it can lead to complications like hematoma or infection.
D. Chart the results on the intake and output flow sheet. While documenting the change is important, charting alone is not an appropriate intervention. The nurse must also assess for possible causes of the decreased drainage and notify the provider.
Correct Answer is C
Explanation
A. Hold the hands higher than the elbows. Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water.
B. Rub hands and arms to dry. Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination.
C. Apply 4 to 5 mL of liquid soap to the hands. The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult.
D. Adjust the water temperature to feel hot. Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.
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