A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

Uses normal saline to irrigate the wound.

Cleans from less soiled to more soiled areas.

Opens a sterile package towards the body.

Places soiled dressing in a plastic bag.

Answer and Explanation

The Correct Answer is C

Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.

Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.

Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.

Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.

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Correct Answer is C

Explanation

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

A. Describing a client's illness in the breakroom without mentioning a name. B. Discussing health history with the client behind a closed curtain. C. Faxing health records to the client's primary healthcare provider. D. Sharing a client's discharge needs with other treatment team members.

Correct Answer is A

Explanation

Choice A reason: Even without mentioning the client's name, discussing health information in a public area like a breakroom can still lead to a HIPAA violation due to the possibility of revealing identifiable information indirectly.

Choice B reason: Discussing health history with a client behind a closed curtain maintains privacy and confidentiality, adhering to HIPAA regulations.

Choice C reason: Faxing health records to a client's primary healthcare provider is a common practice and is not a HIPAA violation if done securely and with proper consent.

Choice D reason: Sharing a client's discharge needs with other treatment team members is necessary for continuity of care and is not a HIPAA violation as long as it is done within the healthcare team.

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A family member is demonstrating wound care using sterile technique. Which action indicates to the nurse that additional teaching is needed?

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Naxlex Comprehensive Predictor Exams

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

Correct Answer is A

Explanation

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

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