Nursing Elites

1. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

• A. Request an interpreter of a different sex from the client
• B. Request a family member or friend to interpret information for the client
• C. Direct attention toward the interpreter when speaking to the client
• D. Review the facility policy about the use of an interpreter

Correct answer: D

Rationale: The correct action for the nurse to take when caring for a client who speaks a different language is to review the facility policy about the use of an interpreter. This ensures compliance with best practices for communication when using interpreters, maintaining accuracy and confidentiality. Requesting an interpreter of a different sex from the client (Choice A) is not relevant to effective communication. Asking a family member or friend to interpret (Choice B) can lead to misinterpretation or breach of confidentiality. Directing attention toward the interpreter (Choice C) is not as crucial as understanding the facility's policy on interpreter use.

2. A healthcare provider is reviewing the laboratory report of a client with a prescription for digoxin. Which result requires withholding the medication?

• A. Digoxin 0.8 ng/mL
• B. Sodium 145 mEq/L
• C. BUN 20 mg/dL
• D. Potassium 3.1 mEq/L

Correct answer: D

Rationale: The correct answer is D. A low potassium level (3.1 mEq/L) can increase the risk of digoxin toxicity. Hypokalemia can potentiate the effects of digoxin on the heart, leading to serious dysrhythmias. Choices A, B, and C are within normal ranges and do not indicate a need to withhold digoxin.

3. A nurse is caring for a client who has depression and reports taking St. John's Wort along with citalopram. The nurse should monitor the client for which condition as a result of an interaction between these substances?

• A. Tardive dyskinesia.
• B. Serotonin syndrome.
• C. Pseudoparkinsonism.
• D. Acute dystonia.

Correct answer: B

Rationale: The correct answer is B: Serotonin syndrome. Serotonin syndrome can occur due to the interaction between citalopram, an SSRI, and St. John's Wort, an herbal supplement. Symptoms of serotonin syndrome include confusion, agitation, rapid heart rate, high blood pressure, dilated pupils, loss of muscle coordination, and sweating. Choices A, C, and D are incorrect as they are not typically associated with the interaction between citalopram and St. John's Wort. Tardive dyskinesia is a movement disorder associated with long-term use of certain medications, pseudoparkinsonism is a side effect of certain antipsychotic medications, and acute dystonia is a movement disorder caused by certain medications like antipsychotics.

4. A nurse is assessing a newborn immediately following birth. Which of the following findings should the nurse report to the provider?

• A. Acrocyanosis
• B. Vernix caseosa
• C. A respiratory rate of 50/min
• D. Heart rate of 160/min

Correct answer: D

Rationale: The correct answer is D, a heart rate of 160/min. A heart rate of 160/min in a newborn exceeds the normal range and could indicate potential issues that need further evaluation by the provider. Acrocyanosis (choice A) is a common finding in newborns and is not concerning. Vernix caseosa (choice B) is a white, cheesy substance found on newborn skin and is a normal finding. While a respiratory rate of 50/min (choice C) is slightly elevated, it is not as concerning as a high heart rate in a newborn.

5. A client has a new diagnosis of COPD. Which of the following instructions should the nurse include in the teaching?

• A. Breathe rapidly through your mouth when using the incentive spirometer.
• B. Use pursed-lip breathing during periods of dyspnea.
• C. Avoid drinking fluids during meals.
• D. Use diaphragmatic breathing during periods of dyspnea.

Correct answer: B

Rationale: Pursed-lip breathing is a beneficial technique for clients with COPD as it helps control shortness of breath and improves oxygenation. This technique involves inhaling slowly through the nose and exhaling through pursed lips, which helps keep airways open. Option A is incorrect as breathing rapidly through the mouth when using the incentive spirometer can lead to hyperventilation. Option C is incorrect because it is important for clients with COPD to stay hydrated by drinking fluids between meals, but not during meals which can cause bloating and discomfort. Option D is incorrect as diaphragmatic breathing, though beneficial, is not the preferred technique for managing dyspnea in COPD; pursed-lip breathing is more effective.

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