Nokea
A Hispanic client is admitted to the surgical unit from the emergency department for an appendectomy. The nurse conducts the preoperative preparations and determines that the client has difficulty understanding English. The surgeon needs to obtain the client's informed consent. The nurse course for obtaining the client's informed consent is to:
- A. Have the client call a family member to act as interpreter
- B. Have the client sign the Spanish surgical consent form
- C. Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions
- D. Notify the surgical charge nurse of the situation
Correct Answer: C
Rationale: The surgeon is required to give the client explanations and have questions answered. The nurse has no way of assessing the client's understanding without the interpreter. The client should sign the Spanish consent form only after receiving an explanation of the procedure, its risks, and alternatives. A family member cannot be relied on to translate the surgeon's instructions accurately.
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The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.
The nurse is assessing a client with a suspected urinary tract infection. Which of the following symptoms is most likely to be present?
- A. Flank pain.
- B. Hypotension.
- C. Bradycardia.
- D. Dry skin.
Correct Answer: A
Rationale: Flank pain is a common symptom of a urinary tract infection, especially if it involves the kidneys.
A client with a history of migraine headaches is prescribed sumatriptan (Imitrex). The nurse should instruct the client to:
- A. Take the medication at the onset of a migraine.
- B. Take the medication daily to prevent migraines.
- C. Avoid taking the medication with food.
- D. Stop the medication if nausea occurs.
Correct Answer: A
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the attack.
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
- A. Resonance
- B. Flatness
- C. Tympany
- D. Dullness
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.
A client with antisocial personality disorder tells the nurse, 'I punched the guy out because he deserved it and then the cops arrested me.' Which of the following responses would be most helpful to the client?
- A. It's wrong to punch others.'
- B. If you punch people out, you'll get into trouble.'
- C. I wouldn't do that again if I were you.'
- D. Don't ever do that again; you're an adult.'
Correct Answer: B
Rationale: Explaining consequences (legal trouble) helps the client understand the impact of their actions, aligning with therapeutic communication for antisocial personality disorder.