Nokea
The nurse is caring for a client who does not speak English. Which of the following actions should the nurse take to facilitate communication with the client? Select all that apply.
- A. Allow the client's spouse to act as the interpreter.
- B. Use short sentences when speaking to the interpreter.
- C. Ask if the client has a gender preference for the interpreter.
- D. Speak directly to the interpreter when providing information.
- E. Ensure the client understands the information provided via the interpreter.
Correct Answer: B,C,E
Rationale: Short sentences aid clarity. Gender preference respects cultural needs. Ensuring understanding confirms effective communication. Using a spouse risks bias, and speaking to the interpreter excludes the client.
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The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
- A. Heart rate
- B. Muscle tone
- C. Cry
- D. Color
Correct Answer: D
Rationale: Color. Acrocyanosis (blue hands and feet) is the most common Apgar score deduction, and is a normal adaptation in the newborn.
The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
- A. Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement.
- B. Advises the client transport technician, 'This client has fragile bones due to cancer, so move the client very carefully.'
- C. Asks a client, 'When were you diagnosed with diabetes?' in a semi-private room with the privacy curtain in place between beds.
- D. Interprets the results of a client's diagnostic testing to the unit clerk
- E. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on which scheduled procedures are logged
Correct Answer: A,D,E
Rationale: Accessing unassigned records , sharing results with a clerk , and writing names on a public whiteboard violate HIPAA. Sharing relevant care info and private questioning are permissible.
Laboratory results
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47) 29%
(0.29)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 9.7 g/dL
97 (g/L)
The nurse is caring for a client with chronic kidney disease who is scheduled to receive recombinant human erythropoietin and iron sucrose. Which of the following actions should the nurse take?
- A. Administer erythropoietin in the client's ventrogluteal muscle.
- B. Check the client's blood pressure prior to administering erythropoietin.
- C. Contact the health care provider to clarify the prescription for iron sucrose.
- D. Hold erythropoietin and inform the health care provider of the laboratory test results.
Correct Answer: B
Rationale: Erythropoietin can increase blood pressure, so checking BP is essential. It's given IV or SC, not IM . Iron sucrose is standard , and holding erythropoietin requires lab evidence.
A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.
Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.