It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?

A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.

A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells.

An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.

A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate.

Answer and Explanation

The Correct Answer is A

Choice A: A practical nurse assisting the healthcare provider with a lumbar puncture at the bedside is a high-risk procedure that requires direct supervision by an RN or a qualified healthcare provider. The RN should ensure the procedure is performed safely and effectively, as it involves potential risks and complications.

Choice B: Starting a transfusion of packed red blood cells is an important nursing intervention, but it does not necessarily require direct supervision by an RN, especially if the nurse has been trained and is competent in administering blood transfusions.

Choice C: Weighing an obese bedfast client using a bed scale is a routine nursing task that can be performed by unlicensed assistive personnel (UAP) with appropriate training. While the RN should ensure that the UAP is properly trained, direct supervision may not be required for this specific task.

Choice D: Accessing a client's implanted port to start an infusion of Ringer's Lactate is a nursing task that can be performed by a graduate nurse, especially if they have received appropriate training and competency validation. Direct supervision by an RN may not be necessary in this situation.

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Correct Answer is A

Explanation

Choice A: When a reflex response is not elicited, it is important to proceed with testing other reflexes later in the exam to assess the overall neurological status. A single absence of a reflex may not be indicative of a problem, so further assessment is needed.

Choice B: Distracting the client by instructing him to pull on his fingers is not an appropriate action when assessing reflexes.

Choice C: Instructing the client to see a neurologist as soon as possible based solely on the absence of one reflex would be premature. Further assessment is needed to determine the significance.

Choice D: Recording the patellar reflex as a zero without further assessment would not provide a comprehensive evaluation of the client's reflexes.

A. "How long has she seemed depressed?" B. "Has she ever attempted suicide before?" C. "Has anything occurred which might have precipitated this suicide attempt?" D. "How did she attempt to kill herself?"

Correct Answer is D

Explanation

Choice A: Inquiring about how long the adolescent has seemed depressed is important for assessing the client's overall mental health history, but it may not provide immediate information about the seriousness of the suicide attempt.

Choice B: Asking about any previous suicide attempts is important for understanding the client's history and risk factors, but it does not directly assess the seriousness of the current attempt.

Choice C: Inquiring about any precipitating events is essential for understanding the context and triggers for the suicide attempt, but it may not be the most immediate question to assess seriousness.

Choice D: Asking "How did she attempt to kill herself?" is the most crucial question to assess the seriousness of the suicide attempt. It provides critical information about the method used, which can help determine the lethality of the attempt and guide immediate interventions and safety measures.

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It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the reflexes of a 35-year-old client who came to the clinic for an annual physical exam. When the nurse strikes the patellar tendon, there is no response. What action should the nurse take next?

Correct Answer is A

Explanation

A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent's suicide attempt, which question is most important for the nurse to ask the family?

Correct Answer is D

Explanation

It is most important for the registered nurse (RN) who is working on a medical unit to provide direct supervision in which situation?

The healthcare provider prescribes amoxicillin-clavulanic acid suspension 300 mg by mouth (PO) three times daily (TID) for a child with a lower respiratory infection. The bottle is labeled," 250 mg/5 mL. How many mL should the nurse administer in a single dose? (Enter numeric value only.)

A 37-year-old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care?

The nurse is planning a nutrition class for vegans. Which food should the nurse encourage to be combined with other foods to enhance the nutritional intake in the vegan diet?

An adult client with a diagnosis of bipolar disorder arrives in an elated state on admission to the psychiatric unit. What is the best room assignment the nurse can make for this client?

The nurse assesses a client's fluid intake at breakfast, which consisted of oatmeal, a cup of milk, and 12 ounces of coffee. How many mL should the nurse document in the client's record? (Enter numerical value only.)

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

A client tells the nurse about taking a variety of herbal products, including milk thistle, and has lost about thirty pounds over the last month. Which action should the nurse implement?