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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:
Herpes simplex virus (HSV) requires contact precautions when there are active lesions. Wearing a cover gown helps prevent the transmission of the virus through direct contact with the client or contaminated surfaces, indicating proper understanding of isolation guidelines.

Choice B Reason:
Protective isolation (also known as reverse isolation) is used for clients who are immunocompromised, and they require a positive airflow room, not a negative airflow room. Positive airflow rooms help keep contaminants out, while negative airflow rooms are used for clients with airborne infectious diseases to prevent the spread of pathogens to other areas.

Choice C Reason:
An N95 respirator mask is required for airborne precautions (e.g., for tuberculosis, measles, or varicella) rather than contact precautions. Contact precautions generally involve wearing gloves and a gown, but an N95 mask is not necessary.

Choice D Reason:
For clients with Clostridium difficile (C. difficile) infection, soap and water must be used for hand hygiene, not alcohol-based hand cleansers. Alcohol-based hand sanitizers are not effective against C. difficile spores, so proper handwashing with soap and water is essential to prevent the spread of this infection.

A. Ensure goals of the facility are being met. B. Make decisions on the unit. C. Delegate tasks to assistive personnel. D. Reward and discipline staff as necessary. E. Monitor overall functions of the unit.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:
Ensuring goals of the facility are being met is correct. Nurse managers are responsible for ensuring that the unit's activities align with the overall goals and objectives of the healthcare facility.
Choice B Reason:
Making decisions on the unit is not necessarily exclusive to the nurse manager role. While nurse managers do have authority to make decisions on the unit, decision-making may also involve collaboration with other members of the healthcare team and may not be solely the responsibility of the nurse manager. Therefore, it's not a specific responsibility that should be included in this context.
Choice C Reason:
Delegating tasks to assistive personnel is correct. Nurse managers delegate tasks to assistive personnel based on their scope of practice and the needs of the unit, ensuring efficient and effective care delivery.
Choice D Reason:
Rewarding and discipline staff as necessary is correct. Nurse managers are responsible for recognizing and rewarding staff for their contributions, as well as addressing performance issues through appropriate disciplinary measures when necessary to maintain a productive work environment.
Choice E Reason:
Monitoring overall functions of the unit is correct. Nurse managers oversee the day-to-day operations of the unit, including staffing, patient care delivery, adherence to policies and procedures, and quality improvement initiatives. They are responsible for ensuring that the unit functions smoothly and efficiently to provide safe and high-quality care to patients.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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