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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Laboratory Results
Glucose - Fasting
70–110 mg/dL
(3.9–6.1 mmol/L) 650 mg/dL
(36.1 mmol/L)
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering?
- A. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours
- B. IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy
- C. IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L)
- D. IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
Correct Answer: C
Rationale: 0.45% saline is appropriate for gastroenteritis to replace fluids. 0.9% saline bolus treats anaphylactic shock. Mannitol reduces intracranial pressure. A 1000 mL bolus for DKA is excessive; smaller boluses (e.g., 250-500 mL) are safer to avoid fluid overload.
The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: B
Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .
The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed
- A. using a slow, steady flow of solution to irrigate the ear canal
- B. placing the client in a lying position with the head tilted toward the affected ear
- C. straightening the ear canal by pulling the pinna down and back
- D. directing the tip of the syringe and irrigation solution toward the top of the ear canal
Correct Answer: C
Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?
- A. Include fibers in your daily diet.
- B. Increase green leafy vegetable intake.
- C. Drink milk for the calcium content.
- D. Eat foods rich in folic acid.
Correct Answer: D
Rationale: Eat foods rich in folic acid. Folic acid is essential for preventing neural tube defects in the developing fetus, making it a critical preconception dietary recommendation.
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
- A. Rapid bounding pulse
- B. Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
- C. Profuse diaphoresis
- D. Slow, irregular respirations
Correct Answer: D
Rationale: Slow, irregular respirations. A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.