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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.
B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.
C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.
D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.
Correct Answer is D
Explanation
Rationale:
A. Stagger care to avoid taking more than one specimen at a time: While staggering procedures can reduce cumulative stress, it is not a primary strategy for obtaining cooperation from a preschooler for a single blood draw.
B. Apply vapocoolant spray immediately prior to collecting the specimen: Vapocoolant sprays can help numb the skin, but their use in preschoolers requires caution, as sudden cold sensations may startle or frighten the child. Additional preparation and explanation are necessary for acceptance.
C. Ask the parents to leave the room prior to collecting the blood specimen: Preschoolers often feel more secure and cooperative when a parent is present. Removing the parent may increase anxiety and resistance to the procedure, so parental support is usually encouraged.
D. Demonstrate the use of the equipment for the child: Preschoolers benefit from simple, age-appropriate explanations and demonstrations of medical equipment. Showing how the equipment works helps reduce fear, build trust, and increase cooperation during the blood draw.
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