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: A subdural hematoma increases complication risk during electroconvulsive therapy (ECT) due to elevated intracranial pressure. ECT-induced seizures can worsen bleeding or cause herniation, posing significant neurological risks. This condition requires careful evaluation, making it the critical risk factor for complications.
Choice B reason: Hyperthyroidism may increase heart rate or metabolic demand but is not a primary risk for ECT complications. With proper management, it poses minimal risk compared to intracranial issues, so this is not the most concerning condition, making it incorrect.
Choice C reason: Renal calculi do not directly impact ECT safety, as they are unrelated to neurological or cardiovascular risks during seizures. This condition is manageable and not a significant complication risk, so it is incorrect for this scenario.
Choice D reason: Diabetes mellitus requires monitoring during ECT due to fasting or medication effects, but it is not a primary risk for complications. With proper glucose management, risks are minimal, so this is incorrect compared to a subdural hematoma’s impact.
Correct Answer is D
Explanation
Choice A reason: Using gauze to cover an infant’s IV site obscures visualization, delaying detection of infiltration or infection. Transparent dressings are preferred, as infants’ small veins are prone to complications. Gauze increases risk by hiding signs like swelling, critical for early intervention in pediatric IV management.
Choice B reason: Monitoring an IV site every 8 hours is inadequate for infants, who need hourly checks due to small vein fragility and high infiltration risk. Frequent assessment detects complications like phlebitis or extravasation early, ensuring vascular integrity and preventing tissue damage in pediatric patients.
Choice C reason: Inserting an IV in the foot is less preferred, as scalp or hand veins are more accessible and stable in infants. Foot IVs risk dislodgement from movement and may impair circulation, increasing complications like tissue damage, making this a suboptimal choice for IV placement.
Choice D reason: A 24-gauge catheter is ideal for infants, as their small veins require smaller needles to minimize trauma and infiltration. This size ensures adequate fluid or medication delivery while reducing vascular damage, aligning with pediatric IV guidelines for safe and effective venous access.
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