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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.

Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.

Collect a stool sample for ova and parasites from a school-age child

Engage a toddler in play.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.

D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.

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Correct Answer is D

Explanation

Rationale:

A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.

B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.

C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.

D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.

A. Apply an ambulation alarm to the client's leg. B. Obtain a prescription to restrain the client PRN. C. Instruct the client in the use of the call light. D. Raise all side rails on the client's bed. E. Check on the client hourly.

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

Explanation

Rationale:

A. Applying an ambulation alarm can help alert staff if the client tries to move independently, thus reducing the risk of falls.

B. Restraints should only be used as a last resort and require a physician’s order. They should not be used routinely for fall prevention.

C. Instructing the client in the use of the call light empowers them to request assistance, which can help prevent falls.

D. Raising all side rails can be considered a restraint and may increase the risk of falls or injury. It is not a recommended practice for fall prevention.

E. Checking on the client hourly ensures ongoing monitoring and timely intervention if needed, which is effective in preventing falls.

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A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?

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Naxlex Comprehensive Predictor Exams

A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

Correct Answer is D

Explanation

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

Explanation

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