Nokea
Which action should the nurse take when working with the interpreter?
- A. Speak in a normal voice at a natural pace.
- B. Use medical jargon to ensure accuracy.
- C. Speak directly to the interpreter instead of the client.
- D. Ask the client to respond only with 'yes' or 'no' answers.
Correct Answer: A
Rationale: The correct answer is A: Speak in a normal voice at a natural pace. This is important because speaking clearly and at a natural pace allows the interpreter to accurately convey the message without missing any information. Using a normal voice also helps maintain a respectful and professional tone during communication.
Choice B is incorrect because using medical jargon may confuse the interpreter and lead to miscommunication. Choice C is incorrect as the nurse should always address the client directly to establish trust and rapport. Choice D is incorrect as it restricts the client's ability to express themselves fully.
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For each potential assessment finding, click to specify if the finding is consistent with chorioamnionitis or preeclampsia. Each finding may support more than one disease process.
Note: Each column must have at least 1 response option selected.
- A. Elevated uric acid level
- B. Blurred vision
- C. Decreased platelet count
- D. Purulent amniotic fluid
- E. Fever
Correct Answer: B,C,D,E
Rationale: Findings like fever, purulent amniotic fluid, decreased platelets, and elevated uric acid support chorioamnionitis. Blurred vision is more indicative of preeclampsia.
Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: C
Rationale: The correct answer is C: A client who is ambulatory and receiving oxygen. This client should be evacuated first because they are at risk for oxygen-related complications during an emergency. Oxygen supports combustion, increasing the risk of fire. The priority is to remove this client from the area to prevent harm. The other choices are incorrect because: A: Although the client is confused and uses a wheelchair, they are not at immediate risk of harm related to their condition. B: The client who is bedridden and wears a hearing aid is also not at immediate risk of harm. D: The client with a fracture in balance suspension traction can be safely evacuated with assistance and does not have an immediate life-threatening condition.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
Which action should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance
- C. Report the findings to the appropriate authorities, following facility protocol
- D. Take photographs of the injuries if permitted, as part of the documentation process
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (Choice C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
- Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
- Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
- Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
- Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
Which of the following actions should the nurse take?
- A. Compare the current infusion with the prescription and the client's medical record.
- B. Adjust the IV infusion rate to match the information received during the shift report.
- C. Stop the infusion immediately and notify the provider.
- D. Document the discrepancy in the client's record and continue monitoring the infusion.
Correct Answer: A
Rationale: The correct answer is A. The nurse should compare the current infusion with the prescription and the client's medical record to ensure accuracy and safety. This step is crucial in preventing medication errors and ensuring that the right medication is given to the right patient at the right time. Adjusting the IV infusion rate without verifying the information can lead to potential harm (choice B). Stopping the infusion immediately and notifying the provider is not necessary unless there is a clear indication of a serious issue (choice C). Documenting the discrepancy and continuing monitoring without taking immediate action can compromise patient safety (choice D).