the nurse observes a nursing assistant performing am care for a client with a new leg cast which action by the assistant will the nurse intervene the nurse observes a nursing assistant performing am care for a client with a new leg cast which action by the assistant will the nurse intervene
Logo

Nursing Elites

NCLEX NCLEX-PN

NCLEX Question of The Day

1. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?

Correct answer: Covering the affected leg with a blanket to avoid chills

Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.

2. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?

Correct answer: Stay with the client, remove the dressing, and elevate the head of bed.

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say “EEE” is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

3. What is the best definition of ethics in nursing?

Correct answer: being able to differentiate right from wrong

Rationale: Ethics in nursing refers to the moral principles that govern a nurse's behavior and decision-making. It involves being able to differentiate right from wrong, making choices that are morally sound, and upholding integrity in patient care. While advocating for the client (choice A) is an important aspect of nursing care, it does not fully encompass the broad concept of ethics. Knowing your scope of practice (choice B) is essential for safe and competent care but is not a comprehensive definition of ethics. Being willing to report violations (choice D) is part of ethical practice, but it is not the core definition of ethics in nursing.

4. The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?

Correct answer: Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay

Rationale: Quality improvement, also known as performance improvement, focuses on processes contributing to client safety and care outcomes. Retrospective audits involve reviewing medical records after discharge for compliance with standards. Concurrent audits assess staff compliance during a client's stay. Therefore, obtaining the medical record from the hospital’s record room for review is crucial in a retrospective audit. Options A, B, and C are more suited for concurrent audits as they involve real-time assessment during a client’s stay.

5. The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?

Correct answer: Body piercing is generally harmless as long as it is performed under sterile conditions

Rationale: Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.

Similar Questions

After securing the client’s safety from a faulty electric bed, what should the nurse do next?
Which of the following statements is correct about Maslow’s hierarchy of needs?
A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client’s ability to maintain a patent airway because of which factor involved in the normal aging process?
A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?
Which of the following statements from a client may indicate that they are at a higher risk for a fall?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99