A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Elevates the head of the client's bed to 30° before inserting a nasogastric tube

Assists the client into a fetal position on his side in preparation for a lumbar puncture

Assesses the client's gag reflex following an esophagogastroduodenoscopy

Maintains the chest tube collection device below the level of the insertion site when ambulating the client

Answer and Explanation

The Correct Answer is A

Choice A Reason:
The patient should be elevated 45-90° before inserting a nasogastric tube helps prevent aspiration and facilitates tube insertion.
Choice B Reason:
Assisting the client into a fetal position on his side in preparation for a lumbar puncture is a proper positioning technique to facilitate the procedure and minimize discomfort for the client.
Choice C Reason:
Assessing the client's gag reflex following an esophagogastroduodenoscopy (EGD) is standard practice to ensure the client's safety and ability to protect their airway after the procedure.
Choice D Reason:
Maintains the chest tube collection device below the level of the insertion site when ambulating the client is correct. Chest tube management is critical to prevent complications such as air leaks, tension pneumothorax, and tube dislodgement. When ambulating a client with a chest tube, it's essential to keep the collection device below the level of the insertion site to ensure proper drainage and prevent air from entering the pleural space. If the collection device is positioned above the insertion site, it could result in fluid or air backflow into the patient's chest cavity, which can lead to complications.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason:
Whether the facility ethics committee reaches a consensus on the case is incorrect. While an ethics committee may provide guidance and recommendations, its decision alone typically does not determine whether a surgery will be performed. Ethics committees are advisory bodies and their decisions may not necessarily override the wishes of the patient or their legal representative.
Choice B Reason:
Whether the client's refusal is based on religious belief is incorrect. Religious beliefs may influence a patient's decision-making process, but they do not automatically determine whether a surgery will be performed. Healthcare decisions are generally based on medical factors, patient autonomy, and legal considerations rather than solely on religious beliefs.
Choice C Reason:
Whether the client understands the risk of refusing the procedure is incorrect. Patient autonomy and informed consent are essential principles in medical ethics. Understanding the risks and benefits of a medical procedure is important for informed decision-making. However, even if the client understands the risks of refusing the procedure, they still have the right to refuse treatment based on their personal preferences and values.
Choice D Reason:
Whether the partner is the client's durable power of attorney for health care is correct. A durable power of attorney for healthcare, also known as a healthcare proxy or surrogate decision-maker, is legally authorized to make medical decisions on behalf of the patient if the patient is unable to do so themselves. If the partner is designated as the client's durable power of attorney for healthcare, they have the legal authority to make decisions regarding the surgery, even if the client refuses. This is because the surrogate decision-maker is tasked with acting in the best interests of the patient when the patient cannot make decisions for themselves.

A. An assistive personnel is informing a friend of the client about their condition. B. A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present. C. An assistive personnel logs out of the computer prior to responding to a call light. D. A nurse is faxing data about a client to a preferred provider. E. A nurse is reviewing an electronic list of all clients admitted to the unit.

Correct Answer is ["A","B","E"]

Explanation

A.This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.

B.Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.

C.This action is a good practice to protect patient information and does not breach confidentiality.

D.This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.

E.If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done?

Correct Answer is D

Explanation

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is teaching a newly licensed nurse about telephone prescriptions. Which of the following information should the nurse include?

A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client refuses to provide a urine sample to check for substance use. Which of the following actions should the nurse take?

A nurse is serving on a committee whose task is to plan cost-effective care at the facility. Which of the following client care tasks should the nurse recommend?

A nurse is assessing a client's comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure?

A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take?

A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective?

A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)