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","B","D"]
Explanation
Rationale:
A. "You sound like you have questions about your mom dying. Let's talk about it.": This response acknowledges the daughter’s emotional struggle and invites open dialogue. It encourages expression of thoughts and feelings, which supports coping and helps build trust.
B. "Tell me how you are feeling about your mom dying.": This therapeutic response promotes emotional expression and validates the daughter’s experience. It allows the nurse to assess the daughter’s understanding, provide reassurance, and offer emotional support.
C. "Hospice will take good care of your mom, so I wouldn't worry about that.": This response minimizes the daughter’s emotions and shuts down communication. It focuses on reassurance rather than addressing the underlying fear or uncertainty the daughter feels about her mother’s death.
D. "Let's talk about your mom's cancer and how things will progress from here.": Providing honest and compassionate information about disease progression helps the daughter prepare emotionally and practically. It also fosters understanding and reduces anxiety about the unknown aspects of dying.
E. "Tell her not to worry. She still has plenty of time left.": Offering false reassurance denies the reality of the situation and prevents the daughter from processing anticipatory grief. Such a response discourages open, honest communication between the client and family.
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.
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