A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor?
Documents client tasks upon completion
Starts a task then determines what supplies are needed
Completes a client assessment while infusing an IV antibiotic over 30 min
Returns to the nurses' station after completing several tasks in the same location
The Correct Answer is B
A is incorrect because documenting client tasks upon completion is an appropriate action by the newly licensed nurse that demonstrates accuracy and timeliness of documentation.
B is correct because starting a task then determining what supplies are needed is an inappropriate action by the newly licensed nurse that indicates poor planning and organization skills.
C is incorrect because completing a client assessment while infusing an IV antibiotic over 30 min is an appropriate action by the newly licensed nurse that demonstrates efficient use of time and multitasking ability.
D is incorrect because returning to the nurses' station after completing several tasks in the same location is an appropriate action by the newly licensed nurse that demonstrates effective prioritization and delegation skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.
Choice B rationale:
Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.
Choice C rationale:
Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.
Choice D rationale:
Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.
Correct Answer is D
Explanation
Choice A rationale:
Suggesting that the client attend adult day care three times per week is incorrect. While social interaction is essential for the elderly, it does not address the specific needs of a client with type 2 diabetes mellitus. Moreover, attending adult day care may not necessarily promote diabetes management.
Choice B rationale:
Reviewing assisted living accommodations with the client is incorrect. Assisted living facilities might be suitable for some elderly individuals, but in this case, the client lives independently. There is no indication in the question stem that the client needs assisted living arrangements at this time.
Choice C rationale:
Discussing a long-term care referral for the client with the provider is incorrect. Long-term care facilities are designed for individuals who require extensive assistance with daily activities. There is no information in the question suggesting that the client's condition has deteriorated to the extent of needing long-term care.
Choice D rationale:
Instructing the client about the use of telehealth services is the correct intervention. Telehealth services, including remote monitoring of blood glucose levels, virtual consultations with healthcare providers, and medication management, can enhance diabetes management for elderly individuals living independently in rural areas. Telehealth provides access to healthcare professionals without the need for frequent travel, addressing the challenges faced by individuals residing in remote areas.
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