A nurse is performing a sterile dressing change and accidentally touches the wound with ungloved hands. What immediate action should the nurse take?
Remove the gloves and continue.
Apply a new dressing without cleaning.
Continue with the dressing change.
Clean the wound with sterile saline.
The Correct Answer is D
Choice A reason: Simply removing the gloves does not correct the contamination that has already occurred. The patient has been exposed to pathogens from the nurse’s skin, and continuing the procedure without addressing this breach in technique fails to uphold the standard of care required to prevent potential site infection.
Choice B reason: Applying a new dressing over a wound that has been touched by an unsterile surface is dangerous. Pathogens may have been introduced into the wound, and failing to cleanse the site before re-dressing it would trap these microorganisms against the wound bed, significantly increasing the risk of an infection.
Choice C reason: Continuing the procedure after a known breach in sterile technique is negligent. The nurse is responsible for maintaining the patient's safety, and proceeding as if the contamination did not happen violates the fundamental principles of medical and surgical asepsis, directly threatening the patient's clinical outcome.
Choice D reason: If a sterile wound is touched by non-sterile hands, it must be considered contaminated. The immediate action is to stop the procedure, replace the sterile gloves, and cleanse the wound bed thoroughly with sterile saline to remove any potential bacteria introduced during the contact before applying a new, sterile dressing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Humanistic therapy focuses on individual self-actualization, empathy, and personal growth, emphasizing the client’s inherent potential. While supportive, it is not the standard model for teaching parents how to manage the specific, structured nutritional requirements and behavioral interventions needed to support an adolescent through an eating disorder recovery process.
Choice B reason: Behavioral therapy targets specific maladaptive behaviors through reinforcement and conditioning. While components of behavioral management are integrated into eating disorder treatment, providing parents with a structured communication framework to facilitate refeeding at home is specifically characteristic of a family-centered systemic approach, rather than generic behavioral conditioning.
Choice C reason: Cognitive behavioral therapy addresses the dysfunctional thought patterns and associated behaviors. Although it is a foundational treatment for anorexia, when the focus specifically shifts to coaching the parent to communicate effectively with the child regarding their eating disorder management, it is classified within the family-based framework.
Choice D reason: Family-based therapy is the gold standard for treating adolescent anorexia nervosa. It empowers parents to play a direct, active role in their child's weight restoration and nutritional stabilization. By coaching the parent on communication strategies, the nurse is utilizing the tenets of this therapy to create a supportive home environment.
Correct Answer is C
Explanation
Choice A reason: Elevating the limb may be helpful for edema, but it is a palliative measure that does not address the underlying etiology of the patient's acute, increased pain. Before implementing interventions, the nurse must perform a comprehensive assessment to determine if the pain is due to a surgical complication.
Choice B reason: Documenting the complaint without assessment constitutes clinical negligence and failure to rescue. A post-surgical patient reporting increased pain requires immediate nursing investigation to rule out serious complications like hemorrhage, dehiscence, or surgical site infection, rather than delaying care until a scheduled assessment time which may be hours away.
Choice C reason: The primary responsibility when a patient reports increased pain at a surgical site is to conduct a thorough physical assessment. This involves inspecting for erythema, purulent drainage, induration, or dehiscence. Identifying these indicators early allows for prompt medical intervention, which is essential for preventing worsening sepsis or systemic complications.
Choice D reason: Administering analgesia before evaluating the source of the pain can mask symptoms of a critical post-surgical complication. It is vital to perform a clinical evaluation, including checking vital signs and inspecting the wound, to ensure the patient is not experiencing a life-threatening issue that requires immediate surgical intervention.
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