Question

Which action by the novice nurse indicates a need for further teaching? A. The nurse fails to wear gloves to remove a dressing. B. The nurse applies an oxygen saturation monitor to the ear lobe. C. The nurse elevates the head of the bed to check the blood pressure. D. The nurse places the extremity in a dependent position to acquire a peripheral blood sample.

Short answer

Answer: Failing to wear gloves to remove a dressing.

Step-by-step solution

Evaluate Option A

Assess the statement for option A - "The nurse fails to wear gloves to remove a dressing." Removing a dressing requires contact with potentially contaminated material or bodily fluids, and wearing gloves is a must for protecting the nurse and the patient. This action is not appropriate and may indicate a need for further teaching.

Evaluate Option B

Consider the statement for option B - "The nurse applies an oxygen saturation monitor to the ear lobe." Placing an oxygen saturation monitor on the earlobe is an acceptable practice when monitoring peripheral capillary oxygen saturation (SpO2) and is not incorrect.

Evaluate Option C

Review the statement for option C - "The nurse elevates the head of the bed to check blood pressure." Elevating the head of the bed is a standard practice when measuring blood pressure, especially for patients with respiratory issues. This action is appropriate and follows proper protocol.

Evaluate Option D

Examine the statement for option D - "The nurse places the extremity in a dependent position to acquire a peripheral blood sample." Positioning the extremity in a dependent position can help increase blood flow to the area and make it easier to obtain a peripheral blood sample. This action is also in line with standard nursing protocol.

Identify the action that requires further teaching

Based on the evaluation of each option, the action that indicates a need for further teaching is Option A - "The nurse fails to wear gloves to remove a dressing."