A nurse is observing an assistive personnel insert an intermittent urinary catheter. Which of the following observed actions would require intervention and further education?

The assistive personnel holds sterile objects above the waist level

The assistive personnel handles the catheter with sterile gloves

The assistive personnel opens the sterile package towards them

The assistive personnel avoids talking over the sterile field

Answer and Explanation

The Correct Answer is C

A. The assistive personnel holds sterile objects above the waist level: This is correct sterile technique because holding objects above waist level helps maintain sterility by preventing contamination from below or the patient’s environment.

B. The assistive personnel handles the catheter with sterile gloves: Using sterile gloves to handle the catheter is essential to prevent introducing pathogens and maintain a sterile field.

C. The assistive personnel opens the sterile package towards them: Opening a sterile package towards oneself increases the risk of contaminating the sterile contents by accidentally touching or breathing on them. The correct technique is to open the package away from the body.

D. The assistive personnel avoids talking over the sterile field: Avoiding talking over the sterile field prevents contamination from respiratory droplets and is an important infection control measure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Place the heel of the hand on the greater trochanter and the index finger on the anterior superior iliac crest: This method is used to locate the ventrogluteal site, not the vastus lateralis.

B. Measure two fingerbreadths below the acromion process: This technique is used to identify the deltoid muscle for IM injections. It is not appropriate when the vastus lateralis is the intended site for medication administration.

C. Ensure to find a place 2 inches away from the umbilicus and free of bruising: This description refers to a subcutaneous injection in the abdomen, commonly used for medications like insulin or heparin, not for IM injections.

D. Measure a handbreadth above the knee and a handbreadth below the greater trochanter: This is the correct technique for locating the vastus lateralis muscle. It ensures the injection is given in the thickest part of the muscle, minimizing the risk of nerve or blood vessel injury.

A. Sign each entry B. Leave blank spaces in charting C. Identify each entry with AM/PM instead of military time (2400 hour cycle). D. Use different color of ink to highlight medication administration.

Correct Answer is A

Explanation

A. Sign each entry: Proper documentation requires each entry to be signed or initialed by the nurse to verify accountability and provide a clear record of who performed the care. This is essential for legal and professional standards.

B. Leave blank spaces in charting: Leaving blank spaces can lead to unauthorized additions or confusion and is discouraged. Documentation should be continuous and clear without gaps to maintain accuracy and integrity.

C. Identify each entry with AM/PM instead of military time (2400 hour cycle): Military time is a standard and accepted practice in healthcare settings for clarity and to avoid confusion between AM and PM. Changing to AM/PM is unnecessary and may increase error risk.

D. Use different color of ink to highlight medication administration: Using different ink colors is not a standard requirement and could complicate documentation consistency. Clear, legible, and accurate entries are more important than color coding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is observing an assistive personnel insert an intermittent urinary catheter. Which of the following observed actions would require intervention and further education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer ceftriaxone 300 mg IM into the right vastus lateralis. Which of the following actions should the nurse take to locate the site of injection?

Correct Answer is D

Explanation

The new nurse works at a hospital that uses paper records. The nurse writes a narrative note about administration of a pain medication, pictured below. Based on documentation guidelines, what is one suggestion that would improve the nurse's charting? Exhibits

Correct Answer is A

Explanation

Which practice by the nurse indicates that the nurse is a professional?

A WOCN is reviewing the wound healing process with a group of nurses on a unit. The WOCN should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply)

When preparing to use a bottle of sterile saline for a dressing change, the nurse notes that the date it was opened was two days ago. What should the nurse do?

The nurse awakens a client while the client is experiencing rapid eye movement sleep. What statement made by the client indicates they were awakened during REM sleep?

A patient is to have peak and trough levels drawn for a particular drug. The nurse explains to the patient that these drug blood levels are important to:

When assessing a patient in the clinic, the nurse identifies which of the following statements as a risk for sensory deficits?

A nurse is documenting information related to a client's condition. When documenting this information in the paper chart, the nurse makes an error documenting vital signs, entering 86/132. What is the best technique for recording the error made in documentation?