It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?
A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.
A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells.
An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.
A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate.
The Correct Answer is A
Choice A: A practical nurse assisting the healthcare provider with a lumbar puncture at the bedside is a high-risk procedure that requires direct supervision by an RN or a qualified healthcare provider. The RN should ensure the procedure is performed safely and effectively, as it involves potential risks and complications.
Choice B: Starting a transfusion of packed red blood cells is an important nursing intervention, but it does not necessarily require direct supervision by an RN, especially if the nurse has been trained and is competent in administering blood transfusions.
Choice C: Weighing an obese bedfast client using a bed scale is a routine nursing task that can be performed by unlicensed assistive personnel (UAP) with appropriate training. While the RN should ensure that the UAP is properly trained, direct supervision may not be required for this specific task.
Choice D: Accessing a client's implanted port to start an infusion of Ringer's Lactate is a nursing task that can be performed by a graduate nurse, especially if they have received appropriate training and competency validation. Direct supervision by an RN may not be necessary in this situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Whole wheat bread is not typically high in tyramine and is not a common trigger for migraines.
Choice B: Chicken is a low-tyramine food and is unlikely to be a trigger for migraines.
Choice C: Cherries are also low in tyramine and are not commonly associated with migraine triggers.
Choice D: Hard salami is a high-tyramine food and is known to be a potential trigger for migraines. Therefore, the nurse should recommend that the client eliminate hard salami from their diet.
Correct Answer is A
Explanation
Choice A: Fluctuation with respiration in the water-seal chamber of the chest drainage system is a normal and expected finding for a client with a chest tube in place. It indicates that the system is functioning correctly and allows for the removal of air or fluid from the pleural space during inspiration and expiration.
Choice B: The condition of the dry gauze dressing over the insertion site is important for monitoring any potential signs of infection or bleeding but does not directly relate to the functioning of the chest tube.
Choice C: No bubbling in the suction chamber of the Pleur-Evac system may indicate that the suction pressure is not adequately transmitted to the chest tube or that there is an issue with the system's seal. This finding is not within normal limits and should be addressed.
Choice D: The presence of serous fluid in the drainage chamber of the Pleur- Evac system is expected and indicates that drainage from the pleural space is occurring. However, the key assessment for proper chest tube function is the fluctuation in the water-seal chamber with respiration.
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