A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in).

When caring for a client's body after death, the nurse elevates the head of the bed.

When providing indwelling catheter care, the nurse uses a clean washcloth, soap, and water.

When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

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Correct Answer is D

Explanation

Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.

Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.

Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.

Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.

A. Provide oral replacement solution. B. Obtain a prescription for antidiarrheal medication. C. Offer the client a sitz bath. D. Collect a specimen of the client's stool.

Correct Answer is A

Explanation

Choice A rationale:

Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.

Choice B rationale:

Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.

Choice C rationale:

Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.

Choice D rationale:

Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.

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A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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