A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?

The nurse positions a client who is postoperative in a semi-Fowler's position.

The nurse uses clean gloves when administering an enema.

The nurse performs auscultation of the lungs without lifting the gown.

The nurse applies a cold compress to reduce localized swelling.

Answer and Explanation

The Correct Answer is C

Rationale:
A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler’s promotes lung expansion and comfort postoperatively, especially after abdominal or thoracic surgery, making this an appropriate nursing action.

B. The nurse uses clean gloves when administering an enema: Clean gloves are sufficient for enema administration since it is a clean (not sterile) procedure, and this reflects correct practice.

C. The nurse performs auscultation of the lungs without lifting the gown: Clothing or gowns interfere with accurate transmission of breath sounds, leading to possible misinterpretation. The gown should be lifted or moved aside to properly auscultate.

D. The nurse applies a cold compress to reduce localized swelling: Cold therapy decreases blood flow and inflammation, making this an appropriate intervention for localized swelling or injury.

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Correct Answer is B

Explanation

Rationale:
A. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm must be refitted after childbirth due to changes in vaginal and cervical anatomy, so continued use without refitting is not recommended.

B. "Place the transdermal birth control patch on your upper outer arm.": The patch should be applied to areas such as the abdomen, buttock, upper torso, or upper outer arm—but not if breastfeeding, as it contains estrogen, which can reduce milk production.

C. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective for the first 6 months postpartum, provided the mother is exclusively breastfeeding and has not resumed menses.

D. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides can be used while breastfeeding. They do not affect milk production or the baby. However, they are not as effective as other methods of contraception and are often used in combination with other methods, such as condoms or diaphragms

A. Assess the client's lung sounds prior to the infusion. B. Prime the infusion tubing with 0.45% sodium chloride. C. Don sterile gloves to prepare the blood administration setup. D. Verify with another nurse that the unit of blood is compatible with the client's blood type. E. Infuse the blood over 4 hr.

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

Explanation

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. Infuse the blood over 4 hr: Each unit of packed RBCs should be transfused within no more than 4 hours to reduce the risk of bacterial contamination and hemolysis from prolonged infusion.

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A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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

Explanation

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