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A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should
- A. use nonverbal communication such as pointing and gestures.
- B. call for the hospital interpreter services.
- C. give the client pen and paper and encourage him to draw.
- D. wait to see if any friends or family visit the client who may be able to help.
Correct Answer: B
Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.
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The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
A 15-year-old client was involved in an auto accident and requires emergency surgery to control bleeding, but both parents are out of town and unable to sign the consent form. Which of the following is the most appropriate action?
- A. The client signs the consent form.
- B. The parents give telephone consent with two witnesses listening.
- C. The parents give email consent.
- D. The physician operates without consent because of the emergency situation.
Correct Answer: D
Rationale: In an emergency where a minor requires life-saving surgery and parents are unavailable, the physician can proceed without consent (D) to save the client's life. Client consent (A), telephone consent (B), or email consent (C) are not appropriate in this urgent situation.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
- A. Lessen the amount of cellular damage
- B. Prevent the formation of blisters
- C. Promote movement
- D. Prevent pain and discomfort
Correct Answer: A
Rationale: Rapid rewarming minimizes cellular damage by restoring blood flow and preventing further tissue injury in frostbite.
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale:
The most appropriate means of rehydration of a 7-month-old with diarrhea and mild dehydration is:
- A. Oral rehydration therapy with an electrolyte solution
- B. Replacing milk-based formula with a lactose-free formula
- C. Administering intraveneous Dextrose 5% 1/4 normal saline
- D. Offering bananas, rice, and applesauce along with oral fluids
Correct Answer: A
Rationale: Oral rehydration therapy with electrolyte solutions is the standard for mild dehydration in infants, as it effectively restores fluid and electrolyte balance.