The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

Notify information services department of the situation.

Wait for notification that the system has been rebooted.

Identify information as late entry in the record.

Print electronic medical record (EMR) from backup server.

Answer and Explanation

The Correct Answer is A

A. Notify information services department of the situation is the correct first step. The nurse should immediately report the issue to the information services department to resolve the problem with the computer system. This ensures that the issue is addressed promptly and minimizes any delays in documentation or patient care.

B. Wait for notification that the system has been rebooted is not the best action. While waiting for the system to reboot might be necessary, the nurse should first notify the information services department to expedite the resolution of the issue.

C. Identify information as late entry in the record may be necessary once the system is restored, but the immediate priority is to report the system failure so that it can be addressed and the documentation can be completed correctly.

D. Print electronic medical record (EMR) from backup server may be an option if the system cannot be restored, but the first step should be to notify the information services department. The backup server can be used if needed after the issue is reported.

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Correct Answer is B

Explanation

A. Clamping the urinary catheter prior to the collection is typically done with clean hands, as the nurse is preparing the catheter for specimen collection. Gloves are not required for this step, as long as proper hand hygiene is performed before and after.

B. Using the syringe to remove the specimen from the catheter is the correct time for the nurse to wear gloves. This step involves direct contact with potentially contaminated urine, and gloves are necessary to maintain infection control and protect the nurse from exposure to bodily fluids.

C. Recording the output on the flowsheet in the client's room does not require gloves, as this step does not involve direct contact with the urine. The nurse should perform proper hand hygiene before and after documenting the output.

D. Transporting the urine specimen to the laboratory does not require gloves, as the specimen is contained in a biohazard bag. Gloves are typically worn during the collection process, but transporting a properly sealed specimen does not require additional protection.

A. Apply sterile-strips. B. Obtain a wound culture. C. Apply a debriding agent. D. Remove every other suture.

Correct Answer is B

Explanation

A. Apply sterile-strips is not the most appropriate action. Steri-strips are typically used for approximating wound edges or supporting sutures, but they are not the first intervention when there is concern about infection or unusual exudate.

B. Obtain a wound culture is the correct action. A thick tan exudate may indicate infection or an abnormal healing process. The nurse should obtain a wound culture to identify the presence of infection and guide appropriate treatment.

C. Apply a debriding agent is premature without first assessing the wound for infection. Debridement is typically used to remove necrotic tissue, but the priority is to determine whether an infection is present before proceeding with debridement.

D. Remove every other suture is not indicated. Sutures should not be removed unless instructed by the healthcare provider, and there is no indication that sutures need to be removed at this time. The focus should be on assessing the wound for infection first.

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The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is B

Explanation

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is B

Explanation

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