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 assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
Which of the following should the nurse use to assess the port?
- A. An Angio catheter
- B. A butterfly needle
- C. A noncoring needle
- D. A 25-gauge needle
Correct Answer: C
Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.
A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation
- B. obtain a throat culture
- C. suction the child's oropharynx
- D. prepare a cool mist tent
Correct Answer: A
Rationale: The correct action is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the airway can become severely compromised due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. Prompt intervention is crucial to prevent respiratory distress and potential death. Obtaining a throat culture (B) may delay essential treatment. Suctioning the oropharynx (C) can stimulate the epiglottis and worsen the obstruction. A cool mist tent (D) does not address the immediate need for securing the airway.
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).
which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Ensure the IV tubing is primed and free of air bubbles before connecting it to the client
- C. Position the IV pump below the level of the client's heart to prevent rapid infusion
- D. Select a catheter gauge of 12 to ensure adequate fluid flow
Correct Answer: B
Rationale: The nurse should choose option B: Ensure the IV tubing is primed and free of air bubbles before connecting it to the client. This is crucial to prevent air embolism, which can be life-threatening. Priming the tubing ensures that only fluid is infused into the client's bloodstream. Air bubbles can travel to the heart and lungs, causing blockages and impairing circulation. Positioning the IV pump below the client's heart (option C) is incorrect as it can lead to rapid infusion and potential complications. Selecting a catheter gauge of 12 (option D) is not always necessary; the appropriate gauge depends on the client's condition and prescribed therapy. Obtaining a surge protector (option A) is irrelevant to the safe administration of IV therapy.