A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?
A client who has Guillain-Barré syndrome and a tracheostomy
A client who has a brain tumor and is admitted for chemotherapy
A client who has multiple sclerosis and ataxia
A client who sustained a concussion and is being monitored for complications
The Correct Answer is D
Choice A Reason:
A client who has Guillain-Barré syndrome and a tracheostomy is incorrect. Guillain-Barré syndrome can be a complex condition, especially when accompanied by a tracheostomy. Caring for a client with this condition requires knowledge and experience in managing respiratory and neurological complications. It may not be suitable for a newly licensed nurse who may require more experience to manage such complex care needs.
Choice B Reason:
A client who has a brain tumor and is admitted for chemotherapy is incorrect. Caring for a client with a brain tumor undergoing chemotherapy involves understanding the effects of both the tumor and the treatment on the client's neurological status and overall well-being. It may require advanced assessment skills and knowledge of potential complications. Assigning this client to a newly licensed nurse may not be appropriate without additional support and supervision.
Choice C Reason:
A client who has multiple sclerosis and ataxia is incorrect. Multiple sclerosis (MS) can present with various neurological symptoms, including ataxia, which affects coordination and balance. Managing the care of a client with MS and ataxia may require familiarity with the disease process, symptom management strategies, and potential complications. It may be more suitable for a nurse with some experience in neurological nursing.
Choice D Reason:
A client who sustained a concussion and is being monitored for complications is correct. Caring for a client with a concussion being monitored for complications is typically within the scope of practice for a newly licensed nurse. Monitoring for changes in neurological status, assessing for signs of increased intracranial pressure, and providing supportive care are tasks that can be managed by a newly licensed nurse under appropriate supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.
Correct Answer is A
Explanation
Choice A Reason:
Withdraws the medication from the ampule using a subcutaneous needle is the correct answer. Medication from an ampule should be withdrawn using a filter needle or a needle specifically designed for ampule use, not a subcutaneous needle. Using the wrong type of needle can lead to contamination or injury to the nurse or the client.
Choice B Reason:
Breaks the top of the ampule using an antiseptic wipe is incorrect answer. Breaking the top of the ampule using an antiseptic wipe helps maintain sterility during the process. It is a standard practice to wipe the neck of the ampule with an antiseptic wipe before breaking it open to reduce the risk of contamination.
Choice C Reason:
Disposes of the ampule by placing it in a sharp’s container is incorrect answer. Disposing of the used ampule in a sharp’s container is the appropriate method for safe disposal of sharps to prevent needlestick injuries.
Choice D Reason:
Performs 3 checks of the medication before administration is incorrect answer. Performing three checks of the medication before administration is a standard safety practice to ensure accuracy and prevent medication errors. This includes checking the medication label against the medication administration record (MAR) or prescription, checking the medication against the MAR or prescription while preparing it, and checking the medication again before administering it to the client.
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