What is the best strategy for communicating with clients with Limited English Proficiency (LEP)?
- A. Ask a family member to translate.
- B. Request a telephonic interpreter.
- C. Request a certified interpreter.
- D. Ask a bilingual staff member to interpret.
Correct Answer: C
Rationale: Certified interpreters ensure accurate and culturally sensitive communication, minimizing errors and misunderstandings.
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What precaution should a nurse take to minimize the risk of death when using potassium chloride to flush a lock or central venous catheter?
- A. Use a dilute form of potassium chloride before flushing locks.
- B. Warm the potassium chloride before flushing locks.
- C. Document on the client’s chart.
- D. Ask the client to implement the instruction.
Correct Answer: A
Rationale: The correct answer is A because concentrated potassium chloride can cause cardiac arrest if injected rapidly.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.
How would you respond to a family member experiencing anticipatory grieving who emotionally withdraws from the client?
- A. Encourage continued engagement and communication.
- B. Allow space while offering support and reassurance.
- C. Advise them to focus solely on practical matters.
- D. Recommend avoiding the client until after their passing.
Correct Answer: B
Rationale: Offering support while respecting emotional withdrawal helps family members process grief at their own pace.
A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant?
- A. Administer IV fluids as prescribed by the physician.
- B. Provide straws and offer fluids between meals.
- C. Develop plan for added fluid intake over 24 hours.
- D. Teach family members to assist client with fluid intake.
Correct Answer: B
Rationale: The nursing assistant can effectively encourage oral fluid intake by offering fluids between meals, which is within their scope of practice. Administering IV fluids, developing plans, and teaching family members are more advanced tasks that require higher-level nursing skills.
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.