The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?
Arrange for unlicensed assistive personnel to assist the PN during the procedure.
Acknowledge that the PN has positioned the client safely and correctly.
Assume care of the client and assign the PN to the care of a different client.
Demonstrate to the PN how to position the client more effectively for the procedure.
The Correct Answer is D
The correct answer is choice D. Demonstrate to the PN how to position the client more effectively for the procedure.
Choice A rationale:
Arranging for unlicensed assistive personnel to assist the PN during the procedure does not address the incorrect positioning of the client. The priority is to ensure the client is positioned correctly for the sigmoidoscopy, which is typically on the left side with knees drawn toward the chest.
Choice B rationale:
Acknowledging that the PN has positioned the client safely and correctly is not appropriate because the flat prone position is incorrect for a sigmoidoscopy. The correct position is on the left side with knees drawn toward the chest.
Choice C rationale:
Assuming care of the client and assigning the PN to the care of a different client does not address the educational opportunity. It is important to demonstrate the correct positioning to the PN to ensure proper care in future procedures.
Choice D rationale:
Demonstrating to the PN how to position the client more effectively for the procedure is the correct action. This ensures the client is in the proper position for the sigmoidoscopy and provides an educational opportunity for the PN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
To calculate the mL/hour for the erythromycin infusion, we first need to determine the infusion rate in mL/minute.
The infusion is to be completed over 30 minutes, which is equal to 0.5 hours. Next, we divide the total volume (100 mL) by the total time (0.5 hours) to get the infusion rate in mL/hour:
Infusion rate = Total volume / Total time
Infusion rate = 100 mL / 0.5 hours Infusion rate = 200 mL/hour
Therefore, the nurse should program the infusion pump to deliver the erythromycin infusion at a rate of 200 mL/hour.
Correct Answer is C
Explanation
Jaw pain in a client taking alendronate, a bisphosphonate, for postmenopausal osteoporosis may be a sign of a rare but serious side effect called osteonecrosis of the jaw (ONJ). Therefore, the nurse should respond by: Report the client's jaw pain to the healthcare provider.
Jaw pain can be an indication of ONJ, a condition characterized by the death of jawbone tissue. It is important to notify the healthcare provider so that further evaluation and appropriate management can be initiated. The healthcare provider will determine the best course of action, which may include referral to a specialist for further assessment and treatment.
Determining how the client is administering the medication is not the immediate concern in this situation. While it is important to ensure that the client is following proper administration instructions for alendronate, addressing the jaw pain takes precedence.
Advising the client to gargle with warm salt water twice daily may not be sufficient or appropriate for managing jaw pain related to alendronate use. The client needs a comprehensive assessment by the healthcare provider to determine the cause of the jaw pain and provide appropriate interventions.
Confirming that jaw pain is a common symptom of osteoporosis is not accurate. While osteoporosis can lead to bone pain, jaw pain specifically associated with bisphosphonate use is more likely to be related to ONJ and requires further evaluation and management
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