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 client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

• A. Musculoskeletal weakness
• B. Loss of appetite
• C. Increased heart rate during physical activity
• D. Left lower extremity tenderness

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

3. The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

• A. Inadequate blood flow leads to decreased tissue ischemia.
• B. Patients with limited caloric intake develop thicker skin.
• C. Pressure reduces circulation to affected tissue.
• D. Verbalization of skin care needs is decreased.

Correct answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

4. A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?

• A. Examine personal values about the issue.
• B. Respect the parents' decision and provide alternative treatment options.
• C. Seek a court order to proceed with the transfusion.
• D. Discuss the issue with the child.

Correct answer: A

Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.

5. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

Similar Questions