Nursing Elites

1. The nurse is performing an admission assessment for a non-English speaking patient who is from China. Which actions could the nurse take to enhance communication (select one that does not apply)?

• A. Use an electronic translation application.
• B. Use a telephone-based medical interpreter.
• C. Wait until an agency interpreter is available.
• D. Ask the patient's teenage daughter to interpret.

Correct answer: D

Rationale: Electronic translation applications, telephone-based medical interpreters, and agency interpreters are all appropriate tools to enhance communication with non-English-speaking patients. However, asking the patient's teenage daughter to interpret is not recommended due to potential misinterpretation of crucial information during the admission assessment. While family members may be considered in the absence of a professional interpreter, there is a risk of misunderstanding or lack of sharing essential details. It is important to rely on trained interpreters to ensure accurate communication and avoid miscommunication or misinterpretation of critical information. Using gestures can be helpful, but over-exaggeration of gestures is unnecessary and may lead to confusion.

2. A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?

• A. Notify the friend that all medical information will be kept confidential.
• B. Explain the relationship to the charge nurse and ask for reassignment.
• C. Approach the client and ask if the assignment is uncomfortable.
• D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When a nurse is assigned to care for a close friend, it is essential to maintain professional boundaries to ensure the best care for the client and the nurse. The most appropriate action for the nurse to take first is to explain the relationship to the charge nurse and ask for reassignment (B). This is important to avoid potential conflicts of interest and maintain objectivity in the care provided. Option A, notifying the friend about confidentiality, may not address the underlying issue of the conflict of interest. Option C, asking the client if the assignment is uncomfortable, may not be appropriate as it puts the client in a difficult position. Option D, accepting the assignment but protecting the client's confidentiality, does not address the conflict of interest and potential ethical issues that may arise from caring for a close friend.

3. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.

4. Which of these is a one-on-one communication between the nurse and another person?

• A. Small-group communication
• B. Intrapersonal communication
• C. Interpersonal communication
• D. Transpersonal communication

Correct answer: C

Rationale: Interpersonal communication is a one-on-one interaction between a nurse and another person that often occurs face-to-face. It involves direct communication between two individuals. Small-group communication involves interaction among a small number of people, not just one-on-one. Intrapersonal communication is internal communication that occurs within an individual's mind. Transpersonal communication involves interactions within a person's spiritual domain, which is beyond individual one-on-one communication.

5. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

• A. EEG
• B. EKG
• C. Electrolytes
• D. Echocardiogram

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

Similar Questions