A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the nurse preceptor?
The nurse positions a client who is postoperative in a semi-Fowler's position.
The nurse uses clean gloves when administering an enema.
The nurse performs auscultation of the lungs without lifting the gown.
The nurse applies a cold compress to reduce localized swelling.
The Correct Answer is C
Rationale:
A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler’s promotes lung expansion and comfort postoperatively, especially after abdominal or thoracic surgery, making this an appropriate nursing action.
B. The nurse uses clean gloves when administering an enema: Clean gloves are sufficient for enema administration since it is a clean (not sterile) procedure, and this reflects correct practice.
C. The nurse performs auscultation of the lungs without lifting the gown: Clothing or gowns interfere with accurate transmission of breath sounds, leading to possible misinterpretation. The gown should be lifted or moved aside to properly auscultate.
D. The nurse applies a cold compress to reduce localized swelling: Cold therapy decreases blood flow and inflammation, making this an appropriate intervention for localized swelling or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Guide the client by walking parallel with them: Clients with visual impairment should be guided by walking slightly ahead of them, allowing them to hold the nurse’s arm and follow safely. Walking parallel can limit spatial awareness and increase the risk of collision or falls.
B. Rearrange clients bedside table items frequently: Frequently moving personal items can confuse a client with reduced vision and increase the risk of injury. Maintaining a consistent environment promotes independence and safety.
C. Remove objects from client's path to the bathroom: Clearing pathways reduces the risk of trips and falls, which is essential for clients with impaired vision. Ensuring a clutter-free environment is a key safety intervention in the plan of care.
D. Use a loud tone of voice when speaking with the client: A louder voice is unnecessary unless the client has a hearing impairment. Communication should focus on clear, descriptive verbal guidance rather than volume, emphasizing orientation and safety.
Correct Answer is C
Explanation
Rationale:
A. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): A normal white blood cell count indicates that the body is not currently mounting an inflammatory or infectious response. This finding does not place the client at risk for developing a wound infection.
B. Temperature 36.8° C (98° F): A normal temperature suggests that the client is afebrile and not showing signs of infection or systemic inflammation. This finding reflects stable postoperative recovery and is not a risk factor for infection.
C. Body mass index of 32: Obesity increases the risk for surgical wound infection because excess adipose tissue has poor blood supply, impairing oxygen and nutrient delivery needed for wound healing. Additionally, increased tension on the incision site can lead to dehiscence and bacterial colonization.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): A normal blood glucose level supports effective immune function and normal wound healing. Hyperglycemia, not euglycemia, would predispose the client to infection by impairing leukocyte function.
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