An experienced nurse on a medical-surgical unit is aware that new research states there is no benefit to rotating intravenous access sites to reduce phlebitis in hospitalized patients. The nurse overhears a new graduate nurse telling a client that they are planning to insert another intravenous line to rotate the site. What is the most appropriate action for the experienced nurse to take?
Tell the new nurse that rotating the access site would cause the client harm.
Ask the new nurse what they understand about the evidence for rotating sites.
Teach the new nurse how to insert a peripheral intravenous line.
Remind the new nurse that research findings should always be applied to practice.
The Correct Answer is B
Rationale:
A. This response is not the most appropriate because it is confrontational and may undermine the new nurse in front of the client. While rotating sites unnecessarily may cause discomfort, simply stating it would cause harm does not promote learning or critical thinking. It also fails to assess the new nurse’s current understanding of evidence-based practice.
B. This is the best response because it uses a supportive, educational approach consistent with professional nursing practice. By asking the new nurse what they understand about the evidence, the experienced nurse encourages critical thinking, assesses knowledge gaps, and creates an opportunity for teaching about current research. This aligns with principles of evidence-based practice and promotes a collaborative learning environment without embarrassing the new nurse.
C. This option is inappropriate because the issue is not about the technical skill of inserting an IV line, but rather about applying current evidence to practice. Teaching a skill does not address the misunderstanding regarding outdated practice.
D. While this statement is true, it is too vague and does not actively engage the new nurse in understanding or applying the evidence. It also misses the opportunity to assess the nurse’s knowledge and guide them toward correct clinical reasoning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Rationale:
A. This client is still awaiting a critical procedure (endoscopy and variceal ligation) for active complications of cirrhosis. Discharge at this point would place the client at high risk for serious bleeding and is unsafe.
B. This client has ongoing symptoms (severe headache) and underlying polycystic kidney disease. Discharging without evaluation of potential complications, such as increased intracranial pressure or hypertension, is unsafe.
C. A client in the recovery phase of acute kidney injury with normalized creatinine is medically stable. They can safely continue recovery at home, making them appropriate for discharge to increase bed availability.
D. Although the potassium level has normalized, the client is still experiencing PVCs. Even three PVCs per minute can indicate ongoing cardiac risk, and discharging this client without cardiac monitoring could be unsafe.
E. A client with acute pancreatitis who now has a normal lipase level and tolerates a low-fat diet is stable and clinically ready for discharge. Symptoms have resolved, labs are normal, and the client can safely continue recovery at home.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. A healthy full-term 1-day-old infant with a strong suck and a healthy mother is considered clinically stable. The infant is feeding well, demonstrating normal neurological and physical adaptation to extrauterine life. The mother is also healthy and able to care for the newborn. Because both mother and infant are stable, early discharge is reasonable with proper home follow-up, making this pair a suitable candidate to free up bed space during a disaster response.
B. A 2-day-old infant with a total serum bilirubin of 8 mg/dL is within normal limits for a healthy newborn at this age. Physiologic jaundice typically peaks around days 3–5 of life and is usually mild in full-term infants. With a healthy mother who can care for the infant and monitor for feeding or jaundice progression, early discharge is safe. This makes the infant appropriate for discharge to increase bed capacity.
C. A 28-hour-old preterm infant born at 34 weeks is high-risk for several complications, including hypoglycemia, temperature instability, apnea, and feeding difficulties. The infant requires ongoing monitoring, potential specialized feeding support, and frequent vital sign assessments. The mother is fatigued, further increasing the need for hospital support. Discharge at this time would be unsafe and could lead to serious complications.
D. A multipara woman who delivered 20 hours ago with an intact perineum is considered medically stable. She has minimal risk for postpartum complications, her vital signs are likely within normal limits, and she can ambulate and care for herself and her infant. Discharge in this situation is safe and appropriate during a surge situation, allowing the hospital to allocate resources to higher-acuity patients.
E. A woman who had a cesarean section and has just been started on IV antibiotics is medically unstable due to postoperative status and ongoing infection treatment. She requires close monitoring for signs of infection, pain control, and surgical site healing. Discharging her at this stage would put her at significant risk for complications and is unsafe.
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