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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A: Partnering with a major pharmaceutical company to provide nebulizers at reduced cost to inner-city children is an example of a secondary prevention strategy aimed at managing asthma symptoms and exacerbations. It does not address primary prevention, which focuses on preventing the development of the condition in the first place.

Choice B: Offering free asthma screening to children at a health fair is a secondary prevention strategy aimed at early detection and management of existing asthma cases. It does not address primary prevention.

Choice C: Informing the city council of the need to strengthen the city's air pollution ordinances is a primary prevention strategy. It aims to address environmental factors (such as air pollution) that can contribute to the development of asthma in children. By reducing exposure to environmental triggers, the goal is to prevent new cases of asthma from occurring.

Choice D: Referring parents of preschoolers with asthma to a support group sponsored by the American Lung Association is a secondary prevention strategy aimed at providing support and education to

A. Position client in left lateral recumbent position to expose buttocks. B. Chill the enema solution to help reduce the client's fever. C. Encourage client to retain solution for at least 5 minutes. D. Insert lubricated tip of tubing 3 to 4 inches into the rectum.

Correct Answer is ["A","C","D"]

Explanation

Choice A: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice B: Chilling the enema solution is not recommended because it can cause cramping, discomfort, and vasoconstriction, which may interfere with the client's fever assessment.

Choice C: Positioning the client in the left lateral recumbent position allows the solution to flow by gravity into the sigmoid colon and rectum.

Choice D: Inserting the lubricated tip of tubing 3 to 4 inches into the rectum prevents injury to the rectal mucosa and ensures proper placement of the tubing.

Choice E: Clamping the enema administration tubing after filling the enema bag is unnecessary and may cause air to enter the tubing, which can increase the risk of abdominal distension and gas pain.

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It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which intervention reflects a primary prevention strategy the nurse might initiate to combat this chronic illness?

Correct Answer is C

Explanation

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

The nurse is admitting an older client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

Which statement by an adolescent client with acute osteomyelitis in the right leg indicates the best understanding of the appropriate activity level after discharge?

A woman is brought to the labor and delivery unit after delivering a full term infant and the placenta in the hospital parking lot 10 minutes ago. What action should the nurse perform first?

Which pathology of autonomic cardiac regulation is mediated by sympathetic innervation?

The practical nurse (PN) is charting vital signs on a hand-written flow sheet and realizes that an error has been made. What should the PN do to rectify this error?

The nurse is caring for an older adult who needs to limit sodium intake. Which food should the nurse encourage the client to avoid?