A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?
Withdraws the medication from the ampule using a subcutaneous needle
Breaks the top of the ampule using an antiseptic wipe
Disposes of the ampule by placing it in a sharp’s container
Performs 3 checks of the medication before administration
The Correct Answer is A
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"The nurse verbalizes their understanding of the plan," is important, verbalizing understanding does not necessarily guarantee successful implementation of the plan. Action is required to demonstrate competence and improvement.
Choice B Reason:
The nurse performs all tasks as specified is correct. The effectiveness of a performance improvement plan is best determined by observing whether the nurse successfully implements the specified tasks and achieves the desired improvements in their performance. Therefore, option B, "The nurse performs all tasks as specified," is the most appropriate outcome to indicate the effectiveness of the plan.
Choice C Reason:
"The nurse attends a critical thinking class," may be a component of the performance improvement plan, but attending a class alone does not necessarily indicate whether the nurse's performance has improved.
Choice D Reason:
"The nurse shares their performance plan with another nurse," is not a direct measure of the effectiveness of the plan. Sharing the plan with another nurse may demonstrate openness and willingness to seek support, but it does not necessarily indicate whether the nurse has successfully improved their performance as a result of the plan.
Correct Answer is D
Explanation
Choice A Reason:
Reinforcing the potential consequences of not having advance directives on record is important, but the immediate priority is to ensure that the missing documentation is obtained.
Choice B Reason:
Reminding nurses to obtain advance directive information during the admission process is a proactive approach to preventing future instances of missing documentation. However, the priority now is to address the current gap in documentation for clients already admitted.
Choice C Reason:
Meeting with nursing staff to review the policy regarding advance directives can provide clarification and reinforcement of expectations, but again, the immediate priority is to address the missing documentation for current clients.
Choice D Reason:
Asking nurses who are caring for clients without this information in the medical record to obtain it. The priority action for the nurse manager is to ensure that advance directives, which are critical documents outlining a patient's wishes regarding medical treatment, are obtained for clients who currently lack documentation. This ensures that patients' preferences and choices regarding their care are respected, especially in critical situations.
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