Nokea
A Turkish-speaking client is scheduled for a colonoscopy, and the nurse must provide printed directions to the client, but directions are not available in Turkish. Which of the following is most appropriate?
- A. The nurse contacts a medical translator to translate.
- B. The client's 10-year-old daughter translates the directions.
- C. The nurse draws pictures and pantomimes directions.
- D. Client's daughter is advised to tell her parent to seek a translator.
Correct Answer: A
Rationale: Contacting a medical translator (A) ensures accurate communication for critical medical instructions. Using a child (B) is unreliable, pictures/pantomime (C) may be unclear, and advising the daughter to find a translator (D) shifts responsibility inappropriately.
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A client is receiving oxygen therapy at 3 L/min per nasal cannula. Which of the following fraction of inspired oxygen (FiO2) measurements does the nurse expect that the client is receiving?
- A. 24%.
- B. 60%.
- C. 32%.
- D. 100%.
Correct Answer: C
Rationale: Nasal cannula at 3 L/min delivers approximately 32% FiO2 (C), as each liter increases FiO2 by about 4% above room air (21%). Other percentages (A, B, D) do not correspond to this flow rate.
The nurse is doing a digital removal of stool for a client with a large fecal impaction resulting from opioid use when the client feels faint, and assessment of vital signs shows a marked decrease in pulse. Which of the following is the most likely reason for the change in pulse rate?
- A. Stimulation of the vagus nerve
- B. Onset of shock
- C. Internal bleeding
- D. Anxiety
Correct Answer: A
Rationale: Digital stool removal can stimulate the vagus nerve (A), causing bradycardia and faintness. Shock (B), bleeding (C), or anxiety (D) are less likely.
A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?
- A. A family history of laryngeal cancer
- B. Chronic inhalation of noxious fumes
- C. Frequent straining of the vocal cords
- D. A history of frequent alcohol and tobacco use
Correct Answer: D
Rationale: Frequent alcohol and tobacco use is the most significant risk factor for laryngeal cancer due to chronic irritation and carcinogenic effects on laryngeal tissues.
The nurse is caring for a client with advanced heart failure and cardiomyopathy. The nurse understands that involving nursing, nutritional services, cardiology, and pharmacy in the client's care team is an example of which approach?
- A. peer review
- B. team nursing
- C. multidisciplinary
- D. community nursing
Correct Answer: C
Rationale: A multidisciplinary approach integrates multiple specialties for comprehensive care, as seen with nursing, nutrition, cardiology, and pharmacy.
Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?
- A. Fever
- B. Red urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.