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The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.
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A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client?
- A. A diet rich in protein and vitamin D will help with absorption.
- B. If the tablet is too large to swallow, crush and take it in applesauce or pudding.
- C. Potassium tablets should be taken on an empty stomach.
- D. Take it with plenty of water and sit upright for a period of time afterward.
Correct Answer: D
Rationale: Potassium chloride tablets should be taken with water and the client should remain upright to prevent esophageal irritation or ulceration (D). Protein and vitamin D (A) do not enhance absorption, crushing tablets (B) can cause irritation, and taking on an empty stomach (C) is unnecessary.
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?
- A. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa)
- B. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa)
- C. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa)
- D. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)
Correct Answer: A
Rationale: PaO2 < 50 mm Hg and PaCO2 > 50 mm Hg (A) indicate acute respiratory failure, requiring immediate intervention. Other options show less severe hypoxemia or normal values.
An adult had a thyroidectomy under local anesthesia and is now in the postanesthesia care unit. Which finding is of most concern to the nurse?
- A. The client complains of a sore throat.
- B. The client's hand involuntarily clenches when the nurse checks the blood pressure.
- C. The client is sitting upright in the bed.
- D. The client asks for a drink of water.
Correct Answer: B
Rationale: Involuntary hand clenching (Trousseau's sign) suggests hypocalcemia from parathyroid damage during thyroidectomy, a serious complication requiring immediate attention. Sore throat, upright position, or thirst are less urgent.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.