Nokea
A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.
- A. Ask the client to nod so the nurse can confirm the client understands the situation
- B. Attempt to use a female interpreter to avoid gender sensitivity
- C. Make good eye contact with the client (rather than the interpreter) when speaking
- D. Preferably use a personal friend or relative to facilitate client privacy under HIPAA
- E. Teach about one intervention at a time and in the order it will occur
Correct Answer: B,C,E
Rationale: A female interpreter respects cultural sensitivity, eye contact with the client fosters trust, and teaching one intervention at a time aids understanding. Friends/relatives as interpreters violate HIPAA.
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The nurse is reviewing new medication prescriptions for assigned clients. The nurse should clarify the prescription for?
- A. PO oxycodone for a client who had a total hip replacement 1 day ago, has a history of buspirone use, and is reporting pain rated as 6 on a scale of 0-10
- B. PO tramadol for a client who had a laparoscopic cholecystectomy 1 day ago, has a history of nicotine use, and is reporting pain rated as 5 on a scale of 0-10
- C. transdermal fentanyl for a client who had an above-the-knee amputation 2 days ago, has a history of cocaine use, and is reporting pain rated as 8 on a scale of 0-10
- D. transdermal lidocaine 5% for a client who has chronic postherpetic neuralgia, has a history of alcohol use, and is reporting pain rated as 7 on a scale of 0-10
Correct Answer: C
Rationale: Transdermal fentanyl is typically reserved for chronic pain, not acute postoperative pain, and requires clarification.
After successful alcohol detoxification, a client remarked to a friend, 'I've tried to stop drinking but I just can't. I can't even work without having a drink.' The client's belief that he needs alcohol indicates his dependence is primarily
- A. psychological
- B. physical
- C. biological
- D. social-cultural
Correct Answer: A
Rationale: With psychological dependence, it is the client's thoughts and attitude toward alcohol that produce craving and compulsive use.
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.
An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported?
- A. Auscultation of a loud heart murmur
- B. Infant has been npo for 4 hours
- C. Infant has polycythemia
- D. Infant has severe diaper rash
Correct Answer: D
Rationale: Severe diaper rash may increase infection risk during catheterization, potentially delaying the procedure.
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.