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 C
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
This statement is more about describing the specific situation (the “D” in DESC) rather than expressing the nurse’s concerns (the “E” in DESC). It’s important to note that the DESC tool stands for Describe, Express, State, and Consequences. In this context, the nurse is merely stating what happened, not expressing how it made them feel or the impact it had on them.
Choice B rationale
This statement accurately represents the “E” component of the DESC tool, which stands for "Express your concerns"12. In this scenario, the nurse is expressing their feelings about the physician’s behavior and its impact on them. They’re stating how the physician’s actions made them feel uncomfortable, especially in front of other staff members and the patient. This is a crucial step in the DESC process as it allows the individual to express their feelings and concerns about the situation.
Choice C rationale
This statement is more aligned with the “S” component of the DESC tool, which stands for "State other alternatives"12. Here, the nurse is suggesting a different way for the physician to express their concerns in the future. While this is an important part of the DESC process, it does not represent the “E” component.
Choice D rationale
This statement represents the “C” component of the DESC tool, which stands for "Consequences stated"12. In this context, the nurse is outlining the potential outcomes if they cannot agree on an alternative approach. While this is a crucial step in the DESC process, it does not represent the “E” component.
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