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 ["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.

A. Administering a rectal suppository for a client who has postoperative constipation. B. Instructing a postoperative client to use an incentive spirometer. C. Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis. D. Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge.

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.

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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 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 on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is D

Explanation

A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

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