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 C

Explanation

Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.

Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.

Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.

Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.

A. Perform a physical assessment. B. Determine an APGAR score. C. Dry the infant under a warming unit. D. Allow the mother to touch the infant.

Correct Answer is D

Explanation

Choice A: Performing a physical assessment of the newborn is important but should not be the first action when the infant is handed to the nurse during a cesarean delivery.

Choice B: Determining an APGAR score is important for assessing the newborn's overall condition, but allowing the mother to touch the infant should be the first action.

Choice C: Drying the infant under a warming unit is an important step to maintain the infant's body temperature, but allowing the mother to touch the infant should be prioritized first.

Choice D: Allowing the mother to touch the infant immediately after delivery is a crucial bonding and comforting moment for both the mother and the newborn. It should be the first action taken before other assessments or interventions.

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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

Following two defibrillation shocks, the client's electrocardiogram (ECG) continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next?

Correct Answer is C

Explanation

The healthcare provider hands a newborn to the circulating nurse during a cesarean delivery. What action should the nurse implement first?

Correct Answer is D

Explanation

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?

A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend?

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.)

The nurse is helping develop a meal plan based on nutritional guidelines for a 73-year-old client being discharge to home with the client's 65- year-old spouse. Which statement best indicates an understanding of the nutritional guidelines when planning meals by the two spouses?

An adult client receives a prescription for permethrin (Acticin Cream 5%) to treat an infestation of scabies. The nurse instructs the client to massage the cream into the skin from the head to the soles of the feet, avoiding the eyes. Which additional instruction should the nurse provide?

An adult male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide?

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?