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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

MRSA is a highly contagious bacteria that can easily spread from person to person through direct contact or contact with contaminated surfaces. By instructing the family to adhere to contact precautions, the nurse can help prevent the spread of MRSA to the client's postoperative wound. Contact precautions typically involve wearing gloves and a gown when in direct contact with the client or the client's immediate environment.

While reporting any increase in the white blood cell count, changing the surgical dressing when soiled, and wearing a face mask during wound care are all important aspects of postoperative care, they are not specifically targeted at preventing the recurrence of MRSA. Adhering to contact precautions is the most effective measure to prevent the spread of MRSA and protect the client from further infection.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield. E. None F. None

Correct Answer is D

Explanation

Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.

Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.

Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.

Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is D

Explanation

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