A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?
Place the client in a dorsal recumbent position for the examination.
Auscultate for vascular bruits with the diaphragm of the stethoscope.
Begin the assessment by using light palpation over the abdomen.
Ensure that the client has a full bladder before beginning the procedure.
The Correct Answer is A
The correct answer is Choice A: Place the client in a dorsal recumbent position for the examination.
Choice A rationale:
The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments. This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.
Choice B rationale:
Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm. The bell is more sensitive to low-frequency sounds like bruits.
Choice C rationale:
The assessment should begin with inspection and auscultation before palpation. Palpation can alter bowel sounds, leading to inaccurate findings.
Choice D rationale:
The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "I delegate tasks to personnel based on their job descriptions."
Choice A rationale:
The response "I delegate tasks to personnel based on their job descriptions" is appropriate in this situation. Charge nurses are responsible for delegating tasks based on the scope of practice and job descriptions of the staff members. This response emphasizes the importance of adhering to established roles and responsibilities within the healthcare team.
Choice B rationale:
The statement "Everyone working here has to care for clients who are incontinent" may be true, but it does not address the specific concern raised by the assistive personnel (AP). It's important to provide a more focused response that addresses the AP's feelings and concerns.
Choice C rationale:
While discussing workflow organization to reduce the number of incontinent clients (Choice C) might be a potential solution, it doesn't directly address the AP's statement about fairness. The charge nurse's response should prioritize explaining the delegation process and addressing the AP's concerns about fairness.
Choice D rationale:
The response "Why do you not want to care for clients who are incontinent?" could be perceived as confrontational and defensive. It's essential to maintain a respectful and supportive tone when addressing staff concerns. This response does not effectively address the situation or provide a solution.
Correct Answer is D
Explanation
Choice A rationale:
Reporting the findings to the hospital ethics committee is not the appropriate action in this scenario. Ventilator-associated pneumonia (VAP) is a clinical issue related to patient care and safety, not an ethical concern. The hospital ethics committee is generally responsible for addressing ethical dilemmas and conflicts.
Choice B rationale:
Alerting central supply is not the correct action in this situation. Central supply typically handles the procurement and distribution of medical supplies, equipment, and materials. While maintaining proper equipment and supplies is important, addressing VAP requires a focus on infection prevention and patient care practices.
Choice C rationale:
Filling out an incident report is not the best course of action for addressing an increase in ventilator-associated pneumonia. Incident reports are typically used to document unexpected events, accidents, or errors that occur in the healthcare setting. However, addressing the rise in VAP involves implementing measures to prevent and control infections, which falls under the purview of the quality improvement team.
Choice D rationale:
The correct action is to notify the quality improvement team. Ventilator-associated pneumonia is a healthcare-associated infection that can lead to serious complications for patients on ventilators. The quality improvement team is responsible for monitoring and improving the quality of patient care, including infection prevention and control. By notifying the quality improvement team, the nurse manager can initiate a comprehensive review of current practices, identify potential areas for improvement, and implement evidence-based interventions to reduce the incidence of VAP.
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