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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Shredding extra copies of a client's records is essential to maintaining confidentiality and protecting the client's privacy. This ensures that sensitive information is properly disposed of and cannot be accessed by unauthorized individuals.
Choice B Reason:
While confirming the fax number before sending the client's information is essential, doing so after sending the information is not useful and can potentially lead to privacy breaches if the information was sent to the wrong number. The correct action would be to verify the fax number before sending the information.
Choice C Reason:
Avoid using a fax cover sheet in order to reduce paper waste is inappropriate. While reducing paper waste is important for environmental sustainability, using a fax cover sheet is typically necessary for providing necessary information and ensuring that the fax is properly directed to the intended recipient. Omitting a fax cover sheet may lead to confusion or misdirection of the faxed information.
Choice D Reason:
Sending the facility, a copy of the client's complete medical record is inappropriate. While it may be necessary to send relevant portions of the client's medical record to the rehabilitative facility, sending the entire medical record may be excessive and could potentially violate the client's privacy rights. It's important to send only the information that is pertinent to the client's transfer and rehabilitation needs.
Correct Answer is D
Explanation
Choice A Reason:
Reinforcing dietary teaching with a client who has heart disease is incorrect. Dietary teaching typically requires a higher level of assessment and critical thinking, often involving interpretation of lab values, medication interactions, and individualized dietary plans. This task is best suited for a Registered Nurse (RN).
Choice B Reason:
Providing postmortem care for a client who has just died is incorrect. Providing postmortem care involves emotional support, respect for the deceased, and proper handling of the body. This task is within the scope of practice for an RN and may also involve collaboration with other healthcare team members.
Choice C Reason:
Accompanying a client who just had a wound debridement to physical therapy is incorrect. Accompanying a client to physical therapy may involve monitoring the client's condition, providing assistance during the transfer, and communicating with the physical therapist about the client's status. This task typically requires an RN or may be appropriate for an assistive personnel under RN supervision.
Choice D Reason:
Obtaining a urine specimen from an older adult client is correct. Obtaining a urine specimen is a task that falls within the scope of practice for an LPN. It involves performing a routine procedure that requires technical skills but does not involve complex assessment or critical thinking beyond following established protocols.
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