Nokea
A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)
- A. Elicit one answer at a time.
- B. Interrupt the interpreter if the response from the family is lengthy.
- C. Comments to the interpreter about the family should be made in English.
- D. Arrange for the family to speak with the same interpreter, if possible.
Correct Answer: A
Rationale: Elicit one answer at a time: By eliciting one answer at a time, the nurse can ensure clarity in communication and prevent confusion or information overload for both the patient and interpreter.
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A client has squamous cell cancer of the right lung that has metastasized to the brain. In addition to chemotherapy for lung cancer, the physician prescribes lomustine (CeeNU), 100 mg/m2 as a single dose, to treat the brain metastasis. What are the major administration and excretion routes of lomustine?
- A. Oral administration and urinary
- B. I.V. administration and urinary excretion
- C. I.V administration and fecal excretion
- D. Oral administration and fecal excretion
Correct Answer: B
Rationale: Lomustine (CeeNU) is typically administered intravenously (I.V.), making choice B the correct administration route. Lomustine is metabolized in the liver and excreted primarily through the kidneys via urine, which accounts for its urinary excretion. Therefore, the major administration route for lomustine is intravenous (I.V.) and the major excretion route is urinary.
The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. What information does the nurse need to include in the response?
- A. Excision of the lesion will be necessary.
- B. Injections of prednisone into the lesion will reduce it.
- C. No treatment is usually necessary because of the high rate of spontaneous involution.
- D. Pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
Correct Answer: C
Rationale: The correct information the nurse should provide to the parents is that no treatment is usually necessary for a strawberry hemangioma because of the high rate of spontaneous involution. Strawberry hemangiomas are common vascular tumors in infants that typically appear in the first few weeks of life. They usually grow rapidly for the first several months and then begin to shrink and eventually disappear on their own. In most cases, the hemangioma resolves without the need for any intervention. Therefore, reassuring the parents that observation is the primary management approach is important, unless complications such as ulceration, bleeding, or obstruction occur.
An adult is to receive an IM injection of Morphine for post op pain. Which of the following is necessary for the nurse to assess prior to giving a narcotic analgesic?
- A. The client's level of alertness and respiratory rate
- B. The last time the client ate or drank something
- C. The client's bowel habits and last bowel movement
- D. The client's history of addictions
Correct Answer: A
Rationale: When administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to monitor for any adverse effects such as respiratory depression. Morphine can cause respiratory depression as one of its side effects, especially in higher doses. By assessing the client's respiratory rate and level of alertness before administering the medication, the nurse can ensure the client's safety and take appropriate action if any signs of respiratory depression occur. This assessment is essential in preventing potential complications and ensuring the client's well-being during pain management.
A 2-year-old male child has an asymptomatic right flank mass discovered incidentally by the mother while bathing. Suspicion of Wilms tumor is raised. Of the following, the LEAST likely investigation to be performed in this child is
- A. plain abdominal radiography
- B. computerized tomography (CT) scan of the abdomen
- C. CT scan of the chest
- D. biopsy of the mass
Correct Answer: D
Rationale: Biopsy is generally avoided in suspected Wilms tumor to prevent upstaging the disease.
gauge needle for drawing up medication and injecting it
- A. Inject the medication in the upper arm muscle
- B. Use a 1 inch needle to administer the medication
- C. Use the Z track technique to administer the medication
Correct Answer: B
Rationale: Using a 1 inch needle is the appropriate gauge needle for drawing up medication and injecting it. The length of the needle is important to ensure that the medication reaches the intended target area and is administered effectively. Shorter needles may not penetrate deep enough, while longer needles may increase the risk of complications such as injecting the medication into the wrong tissue or causing discomfort to the patient. Therefore, using a 1 inch needle is the correct choice for administering medication safely and accurately.