A 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?

Assume care of the client and assign the PN to the care of a different client.

Arrange for unlicensed assistive personnel to assist the PN during the procedure.

Acknowledge that the PN has positioned the client safely and correctly.

Demonstrate to the PN how to position the client more effectively for the procedure.

Answer and Explanation

The Correct Answer is D

Choice A reason: Assuming care of the client and reassigning the PN does not address the immediate need to correct the client's position for the sigmoidoscopy.

Choice B reason: While assistance may be needed, it is more important to first ensure that the client is in the correct position for the procedure.

Choice C reason: Acknowledging the PN's action would be incorrect since the client has not been positioned safely and correctly for a sigmoidoscopy.

Choice D reason: Demonstrating the correct positioning ensures the procedure can be performed effectively and safely, which is the nurse's immediate responsibility.

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Correct Answer is C

Explanation

Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.

Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.

Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.

Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.

A. Review the medical record for the date of insertion. B. Apply ice first, then a warm compress to the IV site. C. Document that the medication was not administered. D. Discontinue the painful IV after a new IV is inserted.

Correct Answer is D

Explanation

Choice A reason: Reviewing the medical record for the date of insertion is important but does not address the immediate concern of pain or potential complications at the IV site.

Choice B reason: Applying ice and then a warm compress may be used for phlebitis or infiltration, but if the client is experiencing pain, the priority is to address the potential for complications.

Choice C reason: Documentation is a necessary step, but it should not be the first action taken when a client reports pain at the IV site.

Choice D reason: If the IV site is painful, it may be indicative of infiltration, phlebitis, or another complication. The nurse should discontinue the painful IV and insert a new one at a different site to prevent further discomfort and potential harm to the client.

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A 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

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

Correct Answer is C

Explanation

While the nurse is preparing a scheduled IV medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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