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
Explanation
Choice A reason: Using three-pronged grounded plugs ensures proper grounding, reducing the risk of electrical fires by safely dissipating excess current. This prevents shocks and short circuits, aligning with National Fire Protection Association (NFPA) standards. Grounded plugs are essential for safe appliance use, making this a critical recommendation for fire prevention education.
Choice B reason: Checking for a tingling sensation around a cord is not a reliable or safe method for fire prevention. Tingling may indicate electrical faults, but proactive measures like inspecting cords for fraying or overheating are more effective. This approach is reactive and risky, as it does not prevent fires, making it inappropriate.
Choice C reason: Covering extension cords with a rug traps heat and increases wear, raising the risk of electrical fires. Cords should be exposed to air and placed to avoid damage or tripping hazards. This practice violates safety guidelines, as it conceals potential issues, making it an incorrect recommendation for fire prevention.
Choice D reason: Removing a plug by pulling the cord can damage insulation or wiring, increasing fire risk due to exposed conductors or short circuits. Plugs should be grasped firmly at the base to remove safely. This action is unsafe and contradicts electrical safety standards, making it an incorrect teaching point.
Correct Answer is C
Explanation
Choice A reason: Experiencing delusions can contribute to agitation, but it is not the strongest predictor of violence. Delusions may lead to unpredictable behavior, but past actions are more reliable indicators, so this factor is less definitive, making it incorrect.
Choice B reason: A history of being in prison indicates past legal issues but not necessarily violent behavior. Incarceration alone is not a direct predictor of future violence, so this factor is less reliable than actual violent history, making it incorrect.
Choice C reason: A history of violent behavior is the best predictor of future violence, as past actions strongly correlate with recurrence, per evidence-based risk assessments. This reliable indicator guides safety planning, making it the correct factor to emphasize in teaching.
Choice D reason: Substance use disorder increases impulsivity and aggression risk, but it is less predictive than a documented history of violence. Substance use is a contributing factor, not the strongest indicator, so this is incorrect compared to past behavior.
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