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A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
- A. Uses a sterile-gloved hand to adjust the back of the sterile gown
- B. Uses sterile forceps to pack sterile gauze into the wound
- C. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
- D. Sets up the sterile field 30 min prior to performing the dressing change
Correct Answer: B
Rationale: Using sterile forceps to pack gauze maintains sterility, reducing infection risk, unlike actions that breach sterile field integrity.
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A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
- A. State nurse practice act
- B. ANA Standards of Practice
- C. ANA Code of Ethics
- D. Institute of Medicine
Correct Answer: A
Rationale: The correct answer is A: State nurse practice act. The state nurse practice act outlines the scope of practice for nurses within a specific state, including the tasks they can perform. Removing chest tubes is a clinical procedure that falls within the scope of nursing practice. Consulting the state nurse practice act ensures that nurses are adhering to the legal and regulatory standards when performing such procedures.
B: ANA Standards of Practice focuses on the general standards of nursing practice but may not provide specific guidance on chest tube removal.
C: ANA Code of Ethics pertains to ethical principles in nursing and does not provide specific guidelines for clinical procedures like chest tube removal.
D: Institute of Medicine focuses on healthcare quality and safety but does not provide specific guidance on nursing procedures.
Therefore, the state nurse practice act is the most appropriate resource for the nurse to consult in planning for the policy on chest tube removal.
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
- A. A prescribed consultation
- B. The client's vital signs
- C. The client's name
- D. The client's code status
Correct Answer: D
Rationale: The correct answer is D: The client's code status. In the background portion of an SBAR report, the nurse should include the client's code status to inform the receiving unit about the client's preferences for resuscitation in case of an emergency. This information is crucial for providing appropriate and individualized care.
A: A prescribed consultation is typically included in the assessment or recommendations sections of the SBAR report, not the background.
B: The client's vital signs are typically included in the assessment section to provide current physiological data.
C: The client's name is already known and is not necessary in the background portion of the report.
E, F, G: These choices are not applicable to the background portion of the SBAR report.
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?
- A. A client who experienced a brief loss of consciousness
- B. A client who has major burns covering 70% of their body
- C. A client who has fixed pupils
- D. A client who has a compromised airway
Correct Answer: D
Rationale: The correct answer is D: A client who has a compromised airway. Assigning a red tag indicates the client needs immediate attention and has life-threatening injuries. A compromised airway can lead to rapid deterioration and death if not addressed promptly, making it the priority. Brief loss of consciousness (A) may not indicate immediate danger. Major burns (B) require urgent care but may not lead to imminent death like an obstructed airway. Fixed pupils (C) suggest neurological issues but may not be immediately life-threatening. In this scenario, ensuring a patent airway is crucial for the client's survival, warranting a red tag assignment.
A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?
- A. Erythema on the skin surrounding a client's wound
- B. Deep red color on the center of a client's wound
- C. Increase in serosanguineous exudate from a client's wound
- D. Inflammation noted on the tissue edges of a client's wound
Correct Answer: B
Rationale: The correct answer is B: Deep red color on the center of a client's wound. This finding indicates wound healing as it suggests the formation of granulation tissue, which is essential for the wound healing process. Granulation tissue is rich in blood vessels and appears deep red in color. This indicates that the wound is in the proliferative phase of healing.
Choice A - Erythema on the skin surrounding a client's wound - Erythema typically indicates inflammation and is not a clear sign of wound healing.
Choice C - Increase in serosanguineous exudate from a client's wound - Increased exudate may indicate inflammation or infection, not necessarily healing.
Choice D - Inflammation noted on the tissue edges of a client's wound - Inflammation suggests the wound is still in the inflammatory phase of healing, not the proliferative phase where granulation tissue forms.
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.