A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Assume care of the client and assign the PN to the care of a different client.

Arrange for unlicensed assistive personnel to assist the PN during the procedure.

Acknowledge that the PN has positioned the client safely and correctly.

Demonstrate to the PN how to position the client more effectively for the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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Correct Answer is B

Explanation

Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.

Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.

Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.

Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.

A. Use standard precautions and wear a mask. B. Explain the purpose of a low bacteria diet. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Monitor the client's white blood cell count.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Standard precautions are always used, but a mask is not specifically required unless performing a procedure that risks splashing. MRSA is primarily spread through direct contact, so masks are not the main precaution for this client.

Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.

Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.

Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.

Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.

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A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide?

Correct Answer is B

Explanation

A client with osteomyelitis from a compound fracture of the left tibia has an open draining wound and is admitted with a possible methicillin-resistant Staphylococcus aureus (MRSA) infection. What intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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