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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Insert a rectal suppository: While a suppository can relieve constipation, abdominal distention after laparoscopic surgery is often caused by retained gas from insufflation rather than stool, so this intervention may not be effective.
B. Assist the client to ambulate: Early ambulation promotes peristalsis and helps the body expel retained carbon dioxide gas from the abdomen, which is a common cause of post-laparoscopic distention. This is a safe and effective first-line intervention.
C. Prepare the client for a paracentesis: Paracentesis is used to remove fluid in cases of ascites, not routine post-surgical gas-related distention. It is unnecessary for uncomplicated laparoscopic procedures.
D. Place the client in the prone position: While repositioning may offer some comfort, it does not significantly facilitate the expulsion of gas or reduce abdominal distention. Ambulation is more effective.
Correct Answer is B
Explanation
Rationale:
A. "Store and eat luncheon deli meats cold while pregnant.": Cold deli meats can harbor Listeria monocytogenes, which can cause listeriosis and increase the risk of miscarriage or fetal infection. Pregnant clients should heat deli meats until steaming before consumption to reduce this risk.
B. "Wash all fruits thoroughly before consumption during pregnancy.": Washing fruits removes dirt, bacteria, and potential contaminants such as Listeria or Toxoplasma, reducing the risk of food-borne illness. This is a key preventive measure for maintaining maternal and fetal health.
C. "Consumption of raw fish is safe during pregnancy if done in moderation.": Raw fish can contain parasites and bacteria such as Salmonella, or Toxoplasma. Pregnant clients should avoid raw or undercooked fish entirely to prevent serious infections that can harm the fetus.
D. "Food-borne illnesses are more difficult to contract while pregnant.": Pregnancy actually increases susceptibility to certain food-borne illnesses due to immunologic changes. Pregnant clients should follow strict food safety measures to protect both maternal and fetal health.
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