A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
The nurse uses clean gloves when discontinuing a client's intravenous infusion.
The nurse uses the client's telephone number as one form of identification when administering medications to a client.
The nurse empties a client's drainable colostomy pouch when it is one-third full.
The Correct Answer is A
Rationale:
A. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C. The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).
D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
Correct Answer is A
Explanation
Rationale:
A. Nuclear family refers to a family unit consisting of two parents and their children. This definition matches the description provided by the parents.
B. Intergenerational family includes multiple generations living together or having frequent contact, which is not the case here.
C. Blended family involves parents who have remarried and may include children from previous relationships, which does not apply here.
D. Extended family includes additional relatives beyond the nuclear family, such as grandparents, aunts, or uncles, which is not the case in this scenario.
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