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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Explaining interventions prior to performing them is a key aspect of patient autonomy. It allows patients to understand what is happening to them and gives them the opportunity to ask questions or refuse treatment if they wish.
Choice B rationale
While keeping patient information private is important and is part of the ethical principle of confidentiality, it does not directly support patient autonomy.
Choice C rationale
Bringing back medication at the stated time supports the principle of beneficence (doing good) and reliability but does not directly support patient autonomy.
Choice D rationale
Providing equal care to all patients is part of the ethical principle of justice, not autonomy.
Correct Answer is A
Explanation
Choice A rationale
During systole, the ventricles contract to pump blood out of the heart to the body and lungs.
Choice B rationale
The ventricles relax during diastole, not systole.
Choice C rationale
The atria also contract during systole, but this occurs just before ventricular systole.
Choice D rationale
This choice is incorrect because both the ventricles and the atria contract during systole.
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