Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Does not let patient know that nurse is assessing respirations.

Auscultating heart sounds using bell of stethoscope.

Assessing both carotid pulse sites at the same time.

Cleaning stethoscope between patient assessments.

Answer and Explanation

The Correct Answer is C

Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.

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Correct Answer is A

Explanation

Choice A rationale
The Quality and Safety Education for Nurses (QSEN) project provides a roadmap to transform nursing by integrating six competencies: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
Choice B rationale
The Institute of Medicine (IOM) is a non-profit organization that provides unbiased and authoritative advice to decision makers and the public. While the IOM has made significant contributions to health care, it does not specifically develop safety competencies for nurses.
Choice C rationale
The Centers for Disease Control (CDC) is a national public health institute in the United States. It conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health.
Choice D rationale
The Health Insurance Portability and Accountability Act (HIPAA) is legislation that provides data privacy and security provisions for safeguarding medical information. While HIPAA contributes to the safety and privacy of patient information, it does not develop safety competencies for nurses.

A. Enlargement of the liver B. Pulmonary congestion C. Cardiac Tamponade D. Peripheral edema

Correct Answer is D

Explanation

Choice A rationale
Enlargement of the liver is not a common complication following a myocardial infarction that has caused damage to the right side of the heart.
Choice B rationale
Pulmonary congestion is more commonly associated with left-sided heart failure.
Choice C rationale
Cardiac Tamponade is a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This can occur as a result of a myocardial infarction, but it is not the most likely complication in this scenario.
Choice D rationale
Peripheral edema is a common complication following a myocardial infarction that has caused damage to the right side of the heart. When the right side of the heart is damaged, it can lead to a backup of blood in the body’s veins, which can cause swelling in the ankles, legs, and abdomen.

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Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing a safety competency designed to reduce the risk of harm to patients and providers through system effectiveness and individual performance. Which group develops these safety competencies?

Correct Answer is A

Explanation

A 67-year-old patient is admitted to the ICU following a myocardial infarction that has caused damage to the right side of the heart. What complication is the patient most likely to experience?

Correct Answer is D

Explanation

The nurse is working at a clinic that assists minority patients. The nurse notes that the physician refuses to use a translator and gives the patients materials only in English. The nurse notes that the physician is guilty of which of the following?

Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Interpret the following arterial blood gas: pH 7.43: HCO3 35: Paco 46.

A patient arrives at the clinic reporting a new onset of angina pectoris that has persisted for the last 30 minutes. What should be the nurse’s initial action?

A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record. Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?

The nurse is caring for a newly admitted client. Which intervention is the best example of a culturally appropriate nursing intervention?

The nurse is assessing the apical pulse. Where should the stethoscope be placed?