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 preceptor?

The nurse places the client in a semi-Fowler’s position for a postoperative assessment.

The nurse auscultates the client’s lungs without lifting the gown.

The nurse administers an enema without checking the client’s chart for contraindications.

The nurse checks the client’s vital signs before administering a cardiac medication.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing the client in semi-Fowler’s position for postoperative assessment is appropriate, promoting lung expansion and reducing aspiration risk. This aligns with standard care, supporting respiratory function and comfort, requiring no further instruction as it reflects safe, evidence-based practice.
Choice B reason: Auscultating lungs without lifting the gown may reduce clarity but is not unsafe. It preserves modesty and is acceptable if effective. While lifting the gown is preferred, this action poses minimal risk, requiring less instruction compared to errors with immediate safety implications.
Choice C reason: Administering an enema without checking for contraindications, like bowel obstruction, risks complications such as perforation. This reflects poor assessment, necessitating instruction to ensure the nurse verifies patient safety and chart details before invasive procedures to prevent harm.
Choice D reason: Checking vital signs before cardiac medication is correct, ensuring safety (e.g., withholding beta-blockers for low heart rate). This follows pharmacological protocols, requiring no instruction, as it demonstrates competence in safe medication administration practices on a medical-surgical unit.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Obtaining initial assessments requires clinical judgment and is outside the scope of assistive personnel (AP). Registered nurses must perform assessments to identify health changes accurately. Delegating this task violates scope of practice regulations, making it illegal and unsafe for AP to perform.
Choice B reason: Changing a nonsterile dressing is within the scope of assistive personnel, as it involves routine, non-invasive care under nurse supervision. AP are trained for such tasks, which do not require clinical judgment, making this a legal and appropriate delegation choice.
Choice C reason: Interpreting laboratory results requires advanced knowledge and clinical decision-making, reserved for registered nurses or providers. Assistive personnel lack the training to analyze results, so delegating this task is illegal and risks patient safety, making it an incorrect choice.
Choice D reason: Educating clients and families involves assessing learning needs and tailoring information, which requires nursing judgment. Assistive personnel are not trained for patient education, making this task outside their scope and illegal to delegate, thus an incorrect choice.

A. Place the client upright on a donut-shaped cushion. B. Turn and reposition the client every 15 minutes while sitting. C. Apply a moisture-barrier cream to the affected area. D. Turn and reposition the client every 3 hours while in bed.

Correct Answer is C

Explanation

Choice A reason: Using a donut-shaped cushion is not recommended, as it can increase pressure on surrounding tissues, worsening ischemia in the ischial area. Nonblanchable erythema indicates early pressure injury, requiring pressure relief and skin protection. This intervention risks further tissue damage, making it inappropriate for managing the client’s condition.
Choice B reason: Repositioning every 15 minutes while sitting is excessive and impractical, potentially causing discomfort or skin shear. For paraplegic clients, repositioning every 1-2 hours while sitting, combined with pressure-relieving cushions, prevents progression of nonblanchable erythema. This frequency is not evidence-based for pressure injury prevention, making it incorrect.
Choice C reason: Applying moisture-barrier cream protects the skin from breakdown in the presence of nonblanchable erythema, an early stage of pressure injury. For paraplegic clients, who are at high risk due to immobility, this intervention reduces moisture-related damage and supports skin integrity, aligning with evidence-based pressure injury prevention strategies.
Choice D reason: Repositioning every 3 hours in bed is insufficient for a paraplegic client with nonblanchable erythema, as guidelines recommend every 2 hours to relieve pressure. Prolonged pressure risks advancing tissue damage, especially in high-risk areas like the ischium. This intervention is inadequate for preventing pressure injury progression.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 preceptor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is making assignments for staff on an inpatient unit. Which of the following tasks can a nurse legally delegate to assistive personnel?

Correct Answer is B

Explanation

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is C

Explanation

A nurse is providing education to a client who is scheduled for a left knee arthroplasty. Which of the following statements regarding informed consent indicates client understanding of the teaching?

A nurse is caring for a client who has an abdominal aortic aneurysm and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

A nurse is assessing a client who has end-stage kidney disease. Which of the following findings should the nurse expect? (Select all that apply)

A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client’s condition is improving?

A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

A nurse is discussing strategies for cost containment with a group of nurse managers. Which of the following statements should the nurse include?

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?