A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?
When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in).
When caring for a client's body after death, the nurse elevates the head of the bed.
When providing indwelling catheter care, the nurse uses a clean washcloth, soap, and water.
When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.
The Correct Answer is A
Answer and explanation
The correct answer is choice A: When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in).
Choice A rationale:
Inserting the enema tip 8 cm (3.1 in) is incorrect as it may cause trauma to the rectal mucosa and result in injury. The appropriate depth for enema tube insertion is typically 3-4 inches for an adult. Going beyond this length increases the risk of reaching higher into the colon, which can lead to discomfort and injury.
Choice B rationale:
Elevating the head of the bed when caring for a deceased client (post-mortem care) is an appropriate action. This helps prevent blood pooling and discoloration in the dependent areas of the body, promoting a more natural appearance during the viewing. This action ensures respectful and dignified care of the deceased.
Choice C rationale:
Using a clean washcloth, soap, and water for indwelling catheter care is incorrect. The appropriate method for catheter care involves cleaning the area around the insertion site with antiseptic solution or the solution provided by the facility. Using soap and water can introduce contaminants and increase the risk of infection.
Choice D rationale:
Using scissors to remove tape securing a peripheral IV catheter is an appropriate action. It helps prevent accidental pulling of the catheter during removal and minimizes patient discomfort. Scissors are a safe tool to detach tape, ensuring a smooth and painless removal process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.
Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.
Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.
Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.
Correct Answer is B
Explanation
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.
Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
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