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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Subjective documentation cannot be quantified. It is based on the patient’s personal experiences and perceptions, which can vary greatly among individuals.
Choice B rationale
A patient’s description is an example of subjective data, not objective data. Subjective data is information that comes directly from the patient and includes their feelings, perceptions, and reported symptoms.
Choice C rationale
Subjective data can incorporate a patient’s emotions. Emotions can provide valuable insights into a patient’s mental and emotional health, which is an important aspect of overall health.
Choice D rationale
A 2-centimeter red wound with exudate is an example of objective data. Objective data is measurable, observable, and can be verified by more than one person.
Correct Answer is A
Explanation
Choice A rationale
Unfreezing is the first stage of Lewin’s Change Theory. It involves overcoming resistance to change and preparing for the upcoming change. In this case, the patient expressing interest in quitting smoking and asking about smoking cessation aids indicates that they are in the unfreezing stage.
Choice B rationale
Moving is the second stage of Lewin’s Change Theory. It involves taking the necessary steps towards change.
Choice C rationale
The term “Action” is not recognized as a stage in Lewin’s Change Theory.
Choice D rationale
Refreezing is the final stage of Lewin’s Change Theory. It involves establishing the change as a new habit, so it becomes the "norm"4.
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