Nursing Elites

1. When working with a client who does not speak the same language as the nurse and an interpreter is present, which of the following actions should the nurse take?

• A. Talk directly to the client, instead of the interpreter, when speaking.
• B. Speak loudly to the interpreter.
• C. Use gestures to communicate with the client.
• D. Avoid using an interpreter and rely on family members.

Correct answer: A

Rationale: When caring for a client who speaks a different language, it is essential to communicate through an interpreter. Talking directly to the client, rather than the interpreter, ensures clear and respectful interaction. Speaking loudly to the interpreter (choice B) is not necessary and may be perceived as disrespectful. Using gestures (choice C) alone may lead to misunderstandings or misinterpretations. Avoiding the use of an interpreter and relying solely on family members (choice D) can compromise the accuracy and confidentiality of the communication.

2. A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

• A. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she 'doesn't like him.'
• B. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions.
• C. The family of a client who has a terminal illness asks the provider not to tell the client the diagnosis.
• D. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications.

Correct answer: C

Rationale: The correct answer is C because an ethical dilemma involves conflicting moral principles. In this scenario, the family's request not to disclose the terminal diagnosis to the client raises the moral question of truth-telling and patient autonomy. Choice A does not present an ethical dilemma but rather a challenge in client compliance. Choice B involves professional responsibility and accountability, not an ethical dilemma. Choice D relates to financial concerns and insurance coverage, which do not constitute an ethical dilemma but rather a financial issue.

3. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

4. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

• A. Check to see if the tubing is kinked.
• B. Increase the IV fluid rate.
• C. Check the catheter insertion site.
• D. Contact the healthcare provider.

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

5. A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: B

Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.

Similar Questions