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 B

Explanation

Choice A rationale:

Using the cane to support body weight is not the correct technique. The purpose of a cane is to provide balance and support, not to bear the entire body weight. Placing the entire body weight on the cane can lead to instability and falls.

Choice B rationale:

Placing the cane next to the unaffected leg (right leg in this case) is the correct technique. This positioning provides additional support and stability on the side opposite to the affected leg. This helps in maintaining balance and reducing the risk of falling.

Choice C rationale:

The type of cane is not as relevant as using it correctly. The material of the cane doesn't impact the client's understanding of how to use it safely. While using a wooden cane might be acceptable, the material itself is not an indication of the client's understanding of safe cane use.

Choice D rationale:

Moving the right leg forward first is not the correct technique for using a cane. The correct foot to move forward first is the affected leg, in this case, the left leg. This allows the client to maintain a stable base of support while moving.

A. Establish the client's learning needs. B. Determine the client's literacy level. C. Evaluate the client's readiness for learning. D. Verify the client's computer access. E. Identify the client's learning style.

Correct Answer is A

Explanation

Choice A rationale:

Before initiating teaching for a client with a new diagnosis of type 2 diabetes mellitus, it is essential to identify the client's learning needs. This involves assessing what the client already knows about the condition, their level of understanding, and any specific areas of concern or interest. By establishing the learning needs, the nurse can tailor the teaching plan to address the client's individual requirements, thereby enhancing the effectiveness of the education provided.

Choice B rationale:

While determining the client's literacy level (Choice B) is important, it might not take precedence over understanding the client's learning needs. However, assessing literacy is still relevant because it helps the nurse adapt the teaching materials and language used to ensure the client comprehends the information.

Choice C rationale:

Evaluating the client's readiness for learning (Choice C) is significant, but it should ideally follow the identification of learning needs. Readiness for learning pertains to the client's emotional and psychological state, which can impact their ability to absorb new information. While essential, it should not be the initial step in planning teaching.

Choice D rationale:

Verifying the client's computer access (Choice D) is not directly related to the immediate planning of teaching for a new diagnosis of type 2 diabetes mellitus. While technology and access to online resources can enhance learning, this consideration is secondary to understanding the client's knowledge gaps and preferred learning style.

Choice E rationale:

Identifying the client's learning style (Choice E) is valuable in customizing the teaching approach, but it comes after establishing learning needs. Learning styles, such as visual, auditory, or kinesthetic, can influence the most effective way to present information. However, without first determining what the client needs to know, tailoring the teaching style might not yield optimal results.

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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

A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

Correct Answer is B

Explanation

A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching?

Correct Answer is A

Explanation

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