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. When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Increased serum hemoglobin levels
• D. Decreased serum potassium levels

Correct answer: B

Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.

3. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to

• A. Assess for abdominal distention
• B. Maintain the infant in an upright position
• C. Begin feeding formula when the infant is alert
• D. Pump the shunt to assess for proper function

Correct answer: A

Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.

4. A healthcare professional is planning to document care provided for a client. Which of the following abbreviations should the professional use?

• A. PC for after meals
• B. QD for every day
• C. BID for twice a day
• D. PRN for as needed

Correct answer: A

Rationale: The correct answer is A: PC for after meals. PC stands for 'post cibum,' which is the appropriate abbreviation for 'after meals' in medical documentation. Choices B, QD, and C, BID, represent 'every day' and 'twice a day,' respectively, which are not specific to meal times. Choice D, PRN, signifies 'as needed,' which is also not related to meal timings. Therefore, for documenting care provided after meals, the most suitable abbreviation is PC.

5. A client is evaluated by a nurse regarding the use of a sequential compression device. Which of the following client statements indicates understanding of the device's purpose?

• A. “This device will keep me from developing skin sores.”
• B. “This device will keep the blood circulating in my leg.”
• C. “This device will prevent my leg muscles from weakening.”
• D. “This device will maintain the health of my joints.”

Correct answer: B

Rationale: The correct answer is B because sequential compression devices are utilized to enhance circulation and prevent clot formation in the legs. Option A is incorrect because these devices are not primarily meant to prevent skin sores. Option C is incorrect because the devices do not directly address muscle weakness. Option D is incorrect as the main purpose of sequential compression devices is not related to joint health.

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