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.

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Correct Answer is A

Explanation

Choice A reason: Abdominal pain is a hallmark of ectopic pregnancy, where the embryo implants outside the uterus, often in the fallopian tube. Tissue stretching or rupture causes localized pain, driven by tubal irritation or internal bleeding, requiring urgent evaluation to prevent life-threatening hemorrhage in affected clients.
Choice B reason: Hydramnios, excessive amniotic fluid, occurs in intrauterine pregnancies, not ectopic ones, which lack a uterine gestational sac. Ectopic pregnancies cannot produce amniotic fluid, as implantation occurs outside the uterus, making hydramnios an irrelevant finding in this condition’s pathophysiology.
Choice C reason: Profuse vaginal bleeding is uncommon in ectopic pregnancy, which typically causes spotting or mild bleeding. Heavy bleeding suggests miscarriage or other conditions. Ectopic pregnancies cause internal bleeding, leading to abdominal pain, not profuse vaginal hemorrhage, a key diagnostic distinction.
Choice D reason: Elevated blood pressure is not typical in ectopic pregnancy unless complicated by pain-induced stress or shock. Internal bleeding from ectopic rupture often lowers blood pressure due to hypovolemia, making hypertension an unlikely finding compared to the expected abdominal pain presentation.

A. This prevents leakage of fluid and medication. B. This helps to keep you hydrated. C. This clears blood from the line. D. This ensures the device is sterile.

Correct Answer is C

Explanation

Choice A reason: Preventing leakage is not the primary purpose of flushing an intermittent infusion device. Flushing maintains patency by clearing blood or medication residue, preventing clots or blockages. Leakage is addressed by proper capping or clamping, not flushing, making this statement incorrect as it misrepresents the procedure’s purpose.
Choice B reason: Flushing an infusion device does not contribute to hydration, as the flush solution (typically saline) is minimal and not intended for fluid replacement. The purpose is to maintain catheter patency by clearing debris or clots. This statement is incorrect, as it inaccurately suggests a hydration benefit unrelated to the procedure.
Choice C reason: Flushing an intermittent infusion device with saline clears blood or medication residue from the catheter, preventing occlusion and maintaining patency. Blood left in the line can clot, increasing infection risk or blocking the device. This statement accurately reflects the procedure’s purpose, ensuring continued functionality for future medication administration.
Choice D reason: Flushing does not ensure sterility, as the device is already in place and exposed to the bloodstream. Sterility is maintained during insertion or access, not flushing. The primary goal is patency, not sterilization, making this statement incorrect as it misaligns with the procedure’s clinical purpose.

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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 caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is flushing a client’s intermittent infusion device. The client states, “Why do you have to do that if you are not giving me medicine?” Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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