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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Diminished breath sounds: Decreased breath sounds could indicate airway obstruction or respiratory compromise but are not a primary sign of hemorrhage following a tonsillectomy. They are more often associated with complications such as laryngospasm or mucus plugging rather than bleeding.

B. Increased drowsiness: Drowsiness in the postoperative period may result from the effects of anesthesia or pain medication. While important to monitor, it is not a specific indicator of hemorrhage unless accompanied by other symptoms like hypotension or tachycardia.

C. Frequent swallowing: Repeated swallowing is an early and classic sign of hemorrhage after tonsillectomy. Children often swallow blood draining down the throat instead of spitting it out, which can lead to blood loss and airway compromise if not promptly addressed.

D. Elevated pain level: Pain is expected after tonsil surgery and does not necessarily indicate bleeding. Although increasing pain should be assessed, it is not a reliable or specific sign of postoperative hemorrhage compared to frequent swallowing.

A. Discourage the client from allowing friends to see the newborn. B. Offer to take pictures of the newborn for the client. C. Assure the client that she can have additional children. D. Avoid talking to the client about the newborn.

Correct Answer is B

Explanation

Rationale:
A. Discourage the client from allowing friends to see the newborn: Restricting contact can hinder the grieving process. Allowing the client and close family or friends to see and hold the baby can help them acknowledge the loss, express emotions, and begin healthy mourning.

B. Offer to take pictures of the newborn for the client: Offering photographs provides the family with tangible memories that can support the grieving and healing process. Many parents later find comfort in having keepsakes, even if they initially decline them.

C. Assure the client that she can have additional children: Statements about future pregnancies minimize the client’s current grief and loss. The nurse should focus on supporting the client’s emotional needs in the present rather than redirecting attention.

D. Avoid talking to the client about the newborn: Avoiding discussion invalidates the client’s feelings and may intensify emotional isolation. Talking about the newborn by name, if known, acknowledges the baby’s existence and validates the parents’ grief, which is essential for emotional healing.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

Correct Answer is B

Explanation

A nurse is preparing a client for discharge home after an admission for bilateral pulmonary emboli. The client is prescribed warfarin in addition to regular daily medications. Which of the following actions should the nurse take?

A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the client indicates an understanding of the teaching?

A nursery nurse is attending the birth of a post-term infant. Exhibits Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

A nurse onapostpartum unit is caring for a client. Exhibits Which of the following provider's prescriptions should the nurse anticipate? Select all that apply?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?

A nurse is caring for a client who has an allergy to penicillin. The health care provider has prescribed amoxicillin. Which of the following actions should the nurse take?