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 C

Explanation

Rationale:
A. Red meat: Red meat is often high in saturated fat and cholesterol, which can contribute to hypertension and cardiovascular disease. Regular consumption may increase blood pressure and arterial stiffness, so clients with hypertension should limit or avoid it.

B. Canned black beans: Although beans are generally healthy, canned varieties are often high in sodium, which can worsen hypertension. Unless the beans are labeled low-sodium or rinsed thoroughly before eating, they can contribute to elevated blood pressure.

C. Fish: Fish, especially fatty varieties like salmon or mackerel, are rich in omega-3 fatty acids, which support cardiovascular health by reducing inflammation and improving lipid profiles. Including fish in the diet promotes heart health and helps manage blood pressure effectively.

D. Cheese: Cheese contains significant amounts of sodium and saturated fat, both of which can increase blood pressure and cardiovascular risk. Clients with hypertension should consume cheese in moderation or select low-sodium, low-fat varieties when possible.

A. Deep tendon patellar reflex B. Heart rate C. Blood pressure D. Edema

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Rationale:

• Deep tendon patellar reflex: The reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia.

• Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms.

• Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment.

• Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.

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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

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

Correct Answer is C

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

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