Nokea
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?
- A. Act as a witness for the informed consent process
- B. Reinforce information about what the client can expect
- C. Report the surgeon to the ethics board for using an inappropriate consent process
- D. Talk to the surgeon privately about using a trained Spanish-language medical interpreter
Correct Answer: D
Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.
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After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?
- A. Client rates leg pain as '7'
- B. Negative Homan sign
- C. Prominent varicose veins bilaterally
- D. Right calf is 4 cm larger than left calf
Correct Answer: D
Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.
The nurse employed in a woman's health care clinic would be most concerned about which client statement?
- A. I recently noticed a small, round, painless, mobile lump in my left breast while showering.
- B. Last night while breastfeeding, my nipples were cracked and my breasts were painful.
- C. My right breast is red and warm with little tiny indented areas on the surface of the skin.
- D. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch.
Correct Answer: C
Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.
What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero?
- A. The disease will incubate longer and progress more slowly in this infant
- B. The infant is very susceptible to infections
- C. Growth and development patterns will proceed at a normal rate
- D. Careful monitoring of renal function is indicated
Correct Answer: B
Rationale: The infant is very susceptible to infections. HIV compromises the immune system, increasing susceptibility to opportunistic infections.
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.
- A. No sexual activity for at least 6 weeks postoperatively
- B. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site
- C. Refrain from lifting objects weighing >5 lb (2.25 kg) until approved by the HCP
- D. Take a shower daily without soaking chest and leg incisions
- E. Use lotion on incision sites when changing dressing if the areas are dry
Correct Answer: B,C,D
Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.