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 preceptor?
The nurse places the client in a semi-Fowler’s position for a postoperative assessment.
The nurse auscultates the client’s lungs without lifting the gown.
The nurse administers an enema without checking the client’s chart for contraindications.
The nurse checks the client’s vital signs before administering a cardiac medication.
The Correct Answer is C
Choice A reason: Placing the client in semi-Fowler’s position for postoperative assessment is appropriate, promoting lung expansion and reducing aspiration risk. This aligns with standard care, supporting respiratory function and comfort, requiring no further instruction as it reflects safe, evidence-based practice.
Choice B reason: Auscultating lungs without lifting the gown may reduce clarity but is not unsafe. It preserves modesty and is acceptable if effective. While lifting the gown is preferred, this action poses minimal risk, requiring less instruction compared to errors with immediate safety implications.
Choice C reason: Administering an enema without checking for contraindications, like bowel obstruction, risks complications such as perforation. This reflects poor assessment, necessitating instruction to ensure the nurse verifies patient safety and chart details before invasive procedures to prevent harm.
Choice D reason: Checking vital signs before cardiac medication is correct, ensuring safety (e.g., withholding beta-blockers for low heart rate). This follows pharmacological protocols, requiring no instruction, as it demonstrates competence in safe medication administration practices on a medical-surgical unit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: Anuria, minimal or no urine output, is expected in end-stage kidney disease (ESKD) due to nephron loss, reducing glomerular filtration rate. This causes fluid and toxin buildup, requiring dialysis to manage fluid balance and prevent complications like uremia in ESKD clients.
Choice B reason: Edema results from impaired sodium and water excretion in ESKD, causing fluid overload. Reduced filtration leads to volume retention, manifesting as peripheral or pulmonary edema, increasing cardiovascular strain and necessitating diuretics or dialysis to control fluid status effectively.
Choice C reason: Hyperkalemia occurs in ESKD, as failing kidneys cannot excrete potassium, elevating serum levels. This risks cardiac arrhythmias due to disrupted membrane potentials. Dietary restrictions or dialysis are needed to manage potassium, preventing life-threatening complications in end-stage renal failure.
Choice D reason: Hypocalcemia in ESKD stems from impaired vitamin D activation and phosphate retention, binding calcium. This disrupts bone mineralization and neuromuscular function, causing tetany or fractures. Calcium supplementation and dialysis correct this imbalance, addressing renal failure’s metabolic consequences.
Choice E reason: Metabolic acidosis in ESKD results from impaired hydrogen ion excretion and bicarbonate reabsorption. This lowers blood pH, causing fatigue and bone demineralization. Dialysis or bicarbonate therapy corrects acid-base imbalances, addressing the kidneys’ failure to maintain homeostasis in end-stage disease.
Correct Answer is B
Explanation
Choice A reason: Obtaining initial assessments requires clinical judgment and is outside the scope of assistive personnel (AP). Registered nurses must perform assessments to identify health changes accurately. Delegating this task violates scope of practice regulations, making it illegal and unsafe for AP to perform.
Choice B reason: Changing a nonsterile dressing is within the scope of assistive personnel, as it involves routine, non-invasive care under nurse supervision. AP are trained for such tasks, which do not require clinical judgment, making this a legal and appropriate delegation choice.
Choice C reason: Interpreting laboratory results requires advanced knowledge and clinical decision-making, reserved for registered nurses or providers. Assistive personnel lack the training to analyze results, so delegating this task is illegal and risks patient safety, making it an incorrect choice.
Choice D reason: Educating clients and families involves assessing learning needs and tailoring information, which requires nursing judgment. Assistive personnel are not trained for patient education, making this task outside their scope and illegal to delegate, thus an incorrect choice.
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