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.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Using two identifiers (e.g., name and medical record number) ensures the correct client receives the medication, preventing errors. This aligns with safety protocols, reducing risks of administering drugs to the wrong person. Verification confirms identity before administration, safeguarding against adverse events and ensuring compliance with standards like The Joint Commission.
Choice B reason: Checking the medication label twice is part of the “rights” of administration but is less specific than using two identifiers for client verification. While important, it addresses medication accuracy, not client identity, which is the primary safety concern to prevent errors, making it less critical in this context.
Choice C reason: Administering medication within 3 hours of the scheduled time relates to timing protocols, not the core action of ensuring safe administration. While timely administration is important, verifying client identity is the priority to prevent errors, as incorrect patient identification can lead to severe adverse events, making this less relevant.
Choice D reason: Administering medications to treat a condition to the actual prescriptions is vague and not a standard safety action. The focus is on verifying client identity and medication accuracy, not a general treatment alignment. This statement does not address a specific, actionable step in safe medication administration, making it incorrect.
Correct Answer is C
Explanation
Choice A reason: Informing the client that consent cannot be withdrawn is incorrect, as clients can revoke consent at any time before or during the procedure. This misrepresents patient rights, making it an unethical and illegal statement for the nurse’s role.
Choice B reason: Identifying risks or discomforts is the surgeon’s responsibility, not the nurse’s, during consent. The nurse verifies understanding and voluntariness, not provides risk details, so this action is outside the nurse’s scope, making it incorrect.
Choice C reason: Ensuring the client understands the procedure and voluntarily agrees is the nurse’s role when witnessing consent. This verifies informed, autonomous decision-making, aligning with legal and ethical standards, making it the correct responsibility for the nurse.
Choice D reason: Providing a detailed surgical technique explanation is the surgeon’s role, not the nurse’s. The nurse ensures comprehension and consent, not technical details, so this action exceeds the nurse’s scope during consent, making it incorrect.
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