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The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.
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The nurse administers intravenous levofloxacin instead of the prescribed azithromycin. Which of the following actions should the nurse take first?
- A. Stop the infusion
- B. Complete an incident report
- C. Obtain vital signs
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: A
Rationale: Stopping the infusion (A) is the first action to prevent further harm from the medication error. Notifying the provider (D), obtaining vital signs (C), and completing an incident report (B) follow after halting the incorrect medication.
A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with
- A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10
- B. new-onset atrial fibrillation who is complaining of chest pain.
- C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4°F (38°C)
- D. advanced Alzheimer's disease who is confused and has had a recent fall.
Correct Answer: B
Rationale: New-onset atrial fibrillation with chest pain (B) suggests possible cardiac ischemia, a life-threatening emergency requiring immediate assessment. Severe pain (A), infected foot wound (C), and confusion post-fall (D) are urgent but less immediately life-threatening.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.
The nurse is caring for assigned clients. The nurse should initially assess the client who was admitted for
- A. intermittent chest pain fourteen hours ago, and the most recent serial troponin level showed no elevation.
- B. syndrome of inappropriate antidiuretic hormone (SIADH) and has developed disorientation within the last two hours.
- C. an acute kidney injury (AKI) four hours ago and has been urinating 15 mL/hr in the indwelling urinary catheter.
- D. observation following a laparoscopic cholecystectomy six hours ago, reporting abdominal cramping radiating to the shoulder.
Correct Answer: B
Rationale: New disorientation in SIADH (B) suggests severe hyponatremia, a neurological emergency requiring immediate assessment. Non-elevated troponin (A), oliguria in AKI (C), and post-cholecystectomy pain (D) are less urgent, though AKI requires monitoring.
The nurse is caring for assigned clients. The nurse should initially follow-up on the client who
- A. has chronic back, neck, and shoulder pain and is crying.
- B. is being treated for pneumonia and reports a persistent cough with thick, yellow mucus.
- C. had a colostomy placed three hours ago and has an edematous stoma with scant bloody drainage.
- D. is being treated for diabetes insipidus, and the family member reports the client has developed confusion.
Correct Answer: D
Rationale: Confusion in diabetes insipidus (D) suggests electrolyte imbalance or dehydration, a critical issue requiring immediate follow-up. Chronic pain with crying (A), pneumonia cough (B), and post-colostomy stoma (C) are less urgent, as they are expected or stable.