The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?

  • The student nurse stops the tube feeding to measure residual.
  • The student nurse lifts the urinary catheter bag up and over the client while turning her.
  • The student nurse scans the client armband and the medication barcode when administering medication.
  • The student nurse observes two other nurses verifying and administering blood to the client while the student nurse records the vital signs just prior to administration.
Number 2 is correct.
Lifting the urinary catheter bag above the client’s bladder allows backflow of urine and increases the risk of a urinary tract infection. The bag should be passed around the end of the bed, not up and over the client. Stopping a tube feeding to check residual is a correct action. Scanning the armband and medication prior to administration is the correct and safe technique to ensure client safety. Recording vital signs and observing other nurses in the blood administration process is educational for the student nurse and demonstrates proper procedure for blood administration.