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. Advise the adolescent to place the newborn for adoption: Suggesting adoption may be perceived as judgmental and does not address the adolescent’s immediate concern about accessing resources and caring for the baby.
B. Refer the adolescent to a local mental health clinic: While emotional support can be beneficial, referral to mental health services alone does not address practical concerns about affording and caring for the baby. Immediate assistance with resources is a priority.
C. Contact the adolescent's parent for assistance: Confidentiality and the adolescent’s autonomy must be respected unless there is a safety concern. The nurse should not contact parents without the adolescent’s consent.
D. Assist the adolescent in applying for Medicaid: Helping the adolescent apply for Medicaid directly addresses her concerns about affording prenatal care and infant needs. This action provides practical support, empowers her to access healthcare and resources, and promotes positive maternal and fetal outcomes.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices
• Compartment syndrome: The child’s nondisplaced midshaft fracture of the radius and ulna places them at risk for compartment syndrome, whereby increased pressure within the muscle compartments impairs circulation and tissue perfusion. Early recognition is crucial to prevent permanent nerve or muscle damage.
• Paresthesia: The child reports tingling in the fingers, which indicates nerve involvement or compression—an early warning sign of compartment syndrome. Monitoring for paresthesia helps the nurse identify worsening neurovascular compromise promptly.
Rationale for Incorrect Choices
• Osteomyelitis: Infection of the bone is unlikely immediately after a closed nondisplaced fracture without open wounds or surgical intervention. There is no evidence of systemic infection at this stage.
• Nonunion: Fracture nonunion is a long-term complication that occurs if healing fails over weeks to months. The child’s fracture is recent, so immediate risk is low.
• Physical damage: While trauma caused the fracture, “physical damage” is a broad term and does not specify a complication requiring acute monitoring.
• Ecchymosis: Bruising indicates soft tissue injury but does not predict compartment syndrome or other severe complications.
• Type of fracture: While important for diagnosis and treatment planning, the fracture type (nondisplaced) does not directly indicate the acute risk for neurovascular compromise.
• Location of fracture: The midshaft location contributes to fracture management but is not as clinically relevant as the early signs of compartment syndrome, such as paresthesia.
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