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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An HbA1c of 7.2% in type 1 diabetes indicates suboptimal control but is not an acute emergency. This client requires follow-up but is stable compared to life-threatening conditions, so they are not require immediate assessment, making this incorrect for prioritization.
Choice B reason: New-onset tachypnea in a hip fracture client suggests a life-threatening issue like pulmonary embolism, a common complication due to immobility. This requires immediate assessment to ensure airway and circulatory stability, aligning with ABC priorities, making it the correct first action for the nurse to take.
Choice C reason: Sinus arrhythmia is typically benign, especially with cardiac monitoring in place. It does not indicate an immediate threat compared to respiratory distress, so this client can be assessed later, making this incorrect for first priority assessment.
Choice D reason: Chest pain in a hypertensive client is concerning for cardiac issues, but tachypnea in a hip fracture suggests a more acute, potentially fatal condition like pulmonary embolism. Respiratory distress takes precedence, so this is incorrect for immediate assessment.
Correct Answer is C
Explanation
Choice A reason: Referring to a mental health clinic addresses potential emotional distress but not the adolescent’s primary concern of affordability. Pregnancy increases psychological stress, but financial barriers to prenatal care are critical. This action fails to ensure access to medical resources, essential for maternal and fetal health in adolescent pregnancy.
Choice B reason: Contacting the adolescent’s parent risks breaching confidentiality, depending on legal guidelines, and does not address financial concerns directly. Family dynamics may complicate support, and without consent, this action could increase stress, failing to provide immediate healthcare access critical for a healthy pregnancy outcome.
Choice C reason: Assisting with Medicaid application directly addresses financial concerns, ensuring access to prenatal care, delivery, and postpartum support. Medicaid reduces risks like preterm birth by covering medical and nutritional needs, critical for adolescent mothers with limited resources, aligning with public health goals for maternal-fetal well-being.
Choice D reason: Advising adoption is premature and overlooks the adolescent’s autonomy. Adoption requires extensive counseling, not immediate recommendation. It fails to address healthcare access, critical for a healthy pregnancy. This approach dismisses financial solutions, potentially increasing stress and undermining informed decision-making in pregnancy.
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