The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

Give positive feedback to the PN and document the skill competency.

Explain to the PN that the sterile sponges are not needed for the procedure.

Remind the PN to wash his hands before applying the sterile gloves.

Ask the PN to remove the gloves and sponges and start over with a new set.

Answer and Explanation

The Correct Answer is D

Choice A reason: Giving positive feedback to the PN and documenting the skill competency is not the appropriate action to take. The PN did not demonstrate proper sterile technique, as he touched the outside of the sterile glove package and the sterile sponges with his bare hands, contaminating them.

Choice B reason: Explaining to the PN that the sterile sponges are not needed for the procedure is not the relevant action to take. The PN may have been following the instructions of the healthcare provider, who may have requested the sponges for the procedure. The issue is not the need for the sponges, but the way the PN handled them.

Choice C reason: Reminding the PN to wash his hands before applying the sterile gloves is not the sufficient action to take. Washing the hands is an important step in maintaining infection control, but it does not correct the mistake the PN made by touching the sterile items with his bare hands.

Choice D reason: Asking the PN to remove the gloves and sponges and start over with a new set is the best action to take. It ensures that the PN follows the correct sterile technique and does not compromise the safety of the client or the procedure. It also provides an opportunity for the charge nurse to teach the PN how to avoid contamination.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Assessing the position of the mask on the client's face is not the priority action. The mask may be well-fitted, but the oxygen delivery may be compromised by the faulty connection of the flowmeter.

Choice B reason: Releasing and reinserting the flowmeter in the wall outlet is the best action as it may correct the problem of the loose or misaligned connection. The nurse should ensure that the flowmeter is securely attached and that the oxygen is flowing properly.

Choice C reason: Attaching the flowmeter to a humidification canister is not necessary for oxygen delivery per mask. Humidification is usually added for high-flow oxygen devices such as nasal cannula or face tent.

Choice D reason: Adjusting the flow rate to the prescribed liters per minute is not the appropriate action. The flow rate may be correct, but the oxygen delivery may be impaired by the hissing sound indicating a leak or obstruction.

A. Complete an adverse occurrence/incident report. B. Demonstrate proper securing of the restraints. C. Ensure that the restraints are not too tight. D. Initiate the facility's restraint flow sheet.

Correct Answer is B

Explanation

Choice A reason: Completing an adverse occurrence/incident report is not the most important action to implement. It may be necessary to document the incident later, but it does not address the immediate safety issue of the client.

Choice B reason: Demonstrating proper securing of the restraints is the best action to implement. It corrects the mistake made by the UAP and ensures that the client is not at risk of injury or entrapment. It also educates the UAP on the correct technique and policy for applying restraints.

Choice C reason: Ensuring that the restraints are not too tight is a relevant action to implement, but not the most important one. It is part of the ongoing assessment and care of the client who is restrained, but it does not correct the improper securing of the restraints to the bedside rails.

Choice D reason: Initiating the facility's restraint flow sheet is a required action to implement, but not the most important one. It is part of the documentation and evaluation of the client who is restrained, but it does not address the immediate safety issue of the client.

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The practical nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the charge nurse observes the PN, which action should the charge nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When initiating oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after inserting the flowmeter into the wall outlet. Which should the nurse do next?

Correct Answer is B

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is entering prescriptions for lab work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

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