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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Radiologic is correct as a "dirty bomb" (radiological dispersal device) involves the dispersal of radioactive materials.
B. Anthrax is a biological agent, not associated with a dirty bomb.
C. Chemical refers to a chemical weapon, which is not what a dirty bomb involves.
D. Sarin is a nerve agent, not related to the concept of a dirty bomb.
Correct Answer is C
Explanation
Rationale:
A. False imprisonment involves restricting a person’s freedom of movement, not administering medication against their will.
B. Assault involves the threat of harm, not the actual administration of medication.
C. Battery is the intentional touching of another person without consent, which includes administering medication to a competent person who has refused it.
D. Negligence involves failure to meet the standard of care, but administering medication against a patient’s wishes is more accurately described as battery.
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