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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to ambulate is not appropriate when the client has a high fever of 40°C (104°F). Ambulation requires physical exertion and can potentially worsen the client's condition, especially when they are already experiencing discomfort due to the fever.

Choice B rationale:

Giving the client a cold sponge bath might seem like a logical approach to reduce fever; however, it is not the most effective and safest method. Cold water can cause vasoconstriction and shivering, potentially increasing the body's metabolic demands and raising the temperature further. Additionally, sudden temperature changes can be uncomfortable and may not provide sustained fever reduction.

Choice C rationale:

Administering antipyretics as prescribed is the correct choice. Antipyretic medications, such as acetaminophen or ibuprofen, work to lower fever by acting on the hypothalamus, the body's temperature-regulating center. By reducing fever, the body's metabolic rate and oxygen consumption are decreased, which can help prevent complications associated with high fever, such as dehydration and discomfort.

Choice D rationale:

Providing a cooling fan can offer some comfort, but it might not be sufficient to effectively lower the client's high fever. Fans primarily work by promoting evaporative cooling, which may not be efficient when the body temperature is significantly elevated. Additionally, relying solely on a cooling fan might delay the necessary intervention of administering antipyretic medication.

A. Dishwashing gloves. B. Adhesive tape. C. Macadamia nuts. D. Bananas. E. Rubber bands.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Dishwashing gloves are often made of latex, which can trigger an allergic reaction in individuals with a latex allergy. Direct contact with latex-containing items should be avoided to prevent allergic responses.

Choice B rationale:

Adhesive tape commonly contains latex and can lead to allergic reactions in individuals with a latex allergy. Avoiding contact with latex-containing items is crucial to prevent potential allergic symptoms.

Choice C rationale:

Macadamia nuts and bananas do not typically contain latex and are not known to trigger latex allergies. While these items can cause allergic reactions in some individuals, they are not relevant to a latex allergy.

Choice D rationale:

While macadamia nuts and bananas can cause allergies in some people, they do not contain latex and are not associated with latex allergies. Therefore, they are not items that the nurse needs to instruct the client to avoid due to their latex allergy.

Choice E rationale:

Rubber bands are often made from latex, which can provoke an allergic reaction in individuals with a latex allergy. Encouraging the client to steer clear of items like rubber bands helps prevent potential allergic responses.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

Correct Answer is C

Explanation

A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).

Correct Answer is ["A","B","E"]

Explanation

A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose?

A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

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?

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?

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?

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?