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 D
Explanation
Rationale:
A. Discuss future treatment options with the client's health care surrogate: The client has decision-making capacity and advance directives in place, so the nurse should honor the client’s wishes rather than deferring to the surrogate.
B. Encourage the client to complete a final hemodialysis treatment: Encouraging treatment contradicts the client’s expressed wishes and advance directives, violating the client’s autonomy and right to refuse care.
C. Contact the client's family to discuss the decision: Family input may be supportive, but the client’s decisions take priority. Involving the family without the client’s consent may undermine autonomy.
D. Discuss possible options for discharge with the client: The nurse should focus on supporting the client’s choices, including end-of-life care and hospice or palliative services, and discuss discharge options that align with the client’s wishes.
Correct Answer is C
Explanation
Rationale:
A. "I should clean my stoma with moisturizing soap.": Moisturizing soaps can leave a residue that interferes with the adhesive seal of the ostomy pouch. The stoma and surrounding skin should be cleaned gently with mild, non-moisturizing soap and water to maintain skin integrity and pouch adhesion.
B. "I should expect my stoma to be blistered.": A healthy stoma should appear pink to red and moist. Blistering indicates trauma, irritation, or infection, which requires assessment and intervention, so this expectation is incorrect.
C. "I should cut my pouch opening 1/8 inch larger than my stoma.": Proper pouch sizing ensures a secure fit around the stoma while protecting the surrounding skin from effluent. Cutting the opening slightly larger than the stoma prevents pressure and irritation.
D. "I should change my stoma pouch 30 minutes after meals.": Ostomy pouch changes should be scheduled when effluent is minimal, typically every 3–7 days or when the pouch is leaking. Timing changes specifically after meals is unnecessary.
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