fundamtal practice b

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? - Talk directly to the clien ...

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? - Talk directly to the client, instead of the interpreter, when speaking - Use a family member as the client's interpreter - Make sure that the interpreter has a college degree - Avoid asking the client personal questions through the interpreter Talk directly to the client, instead of the interpreter, when speaking Rationale: When using an interpreter, the nurse should speak directly to the client and observe the client when the interpreter is translating a nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should LIVE Upgrade to remove ads Only $3/month the nurse include? - Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter - Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min - Make sure the reservior bag of a partial rebreathing mask remains deflated Use petroleum jelly to lubricate the client's nares, face, and lips Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min Rationale: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2) Nice work! You just studied 60 terms! A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? - Talk directly to the client, instead of the interpreter, when speaking - Use a family member as the client's interpreter - Make sure that the interpreter has a college degree - Avoid asking the client personal questions through the interpreter Talk directly to the client, instead of the interpreter, when speaking Rationale: When using an interpreter, the nurse should speak directly to the client and observe the client when the interpreter is translating A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? - Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter - Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min - Make sure the reservior bag of a partial rebreathing mask remains deflated Use petroleum jelly to lubricate the client's nares, face, and lips Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min Rationale: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2) A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? - Loss of skin turgor on the back of the hands - Varicosities on the lower extremities - Thick, discolored nails with ridges - Bruises on the arms in various stages of healing Bruise on the arms in various stages of healing Rationale: Bruises in various stages of healing is an indicator of abuse. Other Start over 1/60 Upgrade to remove ads Only $3/month Terms in this set (60) Original indications include burns, abrasions, fractures, bite marks, dried blood, and pressure ulcers. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? - 2 cups of soup - 1 quart of water - 8 oz of ice chips - 6 oz of tea 8 oz of ice chips Rationale: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals 120 mL of fluid A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? - Reduce dietary sodium - Administer a loop diuretic - Evaluate electrolytes - Restrict intake of oral fluids Evaluate electrolyte Rationale: The first action the nurse should take when using the nursing process is to assess the client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident? - "Incident report completed." - "Client climbed over the bedrails" - "Client found lying on floor" - "Client was trying to get out of bed" "Client found lying on the floor" Rationale: The nurse should include documentation that is descriptive, objective information about what she actually observed, without any opinions or judgement about motive or cause. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client? - "Rashes are very common, especially if you have dry skin. Did it go away on its own?" - "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic." - "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash." - " We need to document the exact medication you were taking because you might be allergic to it." "We need to document the exact medication you were taking because you might be allergic to it." Rationale: If there is any possibility that a client had an allergic reaction to a medication, it is imperative that the provider be aware and does not prescribe that same medication again. Subsequent allergic reactions could be life-threatening. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? - Rock the client up to a standing position - Pivot on the foot that is the farthest from the chair - Assess the client for orthostatic hypotension - Apply a gait belt to the client Assess the client for orthostatic hypotension Rationale: The first action the nurse should take using the nursing process is to assess the client. the nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first? - Reposition the client - Document the client's IV intake in the medical record - Request a new IV fluid prescription - Check the IV tubing for obstruction Check the IV tubing for obstruction