A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?
Elevates the head of the client's bed to 30° before inserting a nasogastric tube
Assists the client into a fetal position on his side in preparation for a lumbar puncture
Assesses the client's gag reflex following an esophagogastroduodenoscopy
Maintains the chest tube collection device below the level of the insertion site when ambulating the client
The Correct Answer is A
Choice A Reason:
The patient should be elevated 45-90° before inserting a nasogastric tube helps prevent aspiration and facilitates tube insertion.
Choice B Reason:
Assisting the client into a fetal position on his side in preparation for a lumbar puncture is a proper positioning technique to facilitate the procedure and minimize discomfort for the client.
Choice C Reason:
Assessing the client's gag reflex following an esophagogastroduodenoscopy (EGD) is standard practice to ensure the client's safety and ability to protect their airway after the procedure.
Choice D Reason:
Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Chest tube management is critical to prevent complications such as air leaks, tension pneumothorax, and tube dislodgement. When ambulating a client with a chest tube, it's essential to keep the collection device below the level of the insertion site to ensure proper drainage and prevent air from entering the pleural space. If the collection device is positioned above the insertion site, it could result in fluid or air backflow into the patient's chest cavity, which can lead to complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A sufficient supply of personal protective equipment is appropriate. Bioterrorism events can involve the deliberate release of biological agents, such as bacteria, viruses, or toxins, with the intent to cause harm to individuals or populations. In such events, personal protective equipment (PPE) is critical for protecting healthcare workers and first responders from exposure to infectious agents and toxins. Adequate supplies of PPE, including masks, gloves, gowns, and eye protection, are essential to ensure the safety of healthcare workers and to prevent the spread of infection.
Choice B Reason:
A network for communication between staff members and families, is important for coordinating care and providing updates during a disaster, but it is not the highest priority when addressing immediate safety concerns related to a bioterrorism event.
Choice C Reason:
A mental health specialist on the response team, is important for providing support to individuals affected by the disaster, but it is not the highest priority during the initial response phase focused on safety and containment.
Choice D Reason:
A system for tracking client information, is important for maintaining continuity of care and tracking patient outcomes, but it is not the highest priority in the immediate response to a bioterrorism event when protecting healthcare workers and preventing further spread of infection is paramount.
Correct Answer is C
Explanation
Choice A Reason:
Respiratory therapist is incorrect. While a respiratory therapist may be involved in the management of asthma, their role primarily focuses on providing respiratory treatments and therapies. They may not have direct involvement in assisting with financial or resource-related issues.
Choice B Reason:
Child protective services is incorrect. Child protective services are typically involved in cases of suspected abuse or neglect. The inability to afford a nebulizer for asthma management does not constitute a situation requiring the involvement of child protective services.
Choice C Reason:
Social worker is correct. Social workers are trained to assist individuals and families in accessing resources and support services, including financial assistance programs or community resources that may provide assistance with obtaining medical equipment such as a nebulizer.
Choice D Reason;
Pharmacist is incorrect. While a pharmacist may provide information and guidance on medications and medical devices, their role may be limited in addressing financial barriers to obtaining a nebulizer. Social workers are better equipped to assist with navigating financial challenges and accessing resources for healthcare needs.
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