Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take?
A. Obtain a board that uses colored pictures as communication.
Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B. Request an interpreter during the initial assessment.
Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C. Familiarize themselves with commonly used signed language.
Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.
D. Ask a family member to be present during the admission.
Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Med Surg 2023 Proctored Exam. Take the full exam now
Full Explanation
A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.
D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.
Similar Questions
A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take?
A. Dispose of the top of the ampule in a sharps container.
Disposing of the top of the ampule in a sharps container is essential for safety to prevent accidental injuries from broken glass.
B. Place a paper towel around the ampule's neck to break off the top with both hands.
While placing a paper towel around the ampule's neck to break off the top with both hands is a good practice to prevent injury, it's not the primary action needed for safe disposal.
C. Expel air into the ampule to aspirate air bubbles.
Expelling air into the ampule to aspirate air bubbles is unnecessary and could contaminate the medication.
D. Withdraw the medication from the ampule using a needleless system.
Withdrawing the medication from the ampule using a needleless system is not typically done with ampules, as they are usually designed for single-use and require breaking the top off to access the medication.
Full Explanation
A) Disposing of the top of the ampule in a sharps container is essential for safety to prevent accidental injuries from broken glass.
B) While placing a paper towel around the ampule's neck to break off the top with both hands is a good practice to prevent injury, it's not the primary action needed for safe disposal.
C) Expelling air into the ampule to aspirate air bubbles is unnecessary and could contaminate the medication.
D) Withdrawing the medication from the ampule using a needleless system is not typically done with ampules, as they are usually designed for single-use and require breaking the top off to access the medication.
A nurse is reviewing the medical record of a client who has nephrotic syndrome.
Which of the following findings should the nurse expect?
A. Decreased coagulation
Nephrotic syndrome is not typically associated with decreased coagulation.
B. Proteinuria
Proteinuria, or the presence of excessive protein in the urine, is a hallmark finding of nephrotic syndrome.
C. Decreased serum lipid levels
Nephrotic syndrome is actually associated with increased serum lipid levels.
D. Hyperalbuminemia
Hyperalbuminemia is not typically associated with nephrotic syndrome; rather, hypoalbuminemia is more common due to loss of albumin in the urine.
Full Explanation
A) Nephrotic syndrome is not typically associated with decreased coagulation.
B) Proteinuria, or the presence of excessive protein in the urine, is a hallmark finding of nephrotic syndrome.
C) Nephrotic syndrome is actually associated with increased serum lipid levels.
D) Hyperalbuminemia is not typically associated with nephrotic syndrome; rather, hypoalbuminemia is more common due to loss of albumin in the urine.
A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?
A. Administer the transfusion through a 25-gauge saline lock.
Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B. Administer the plasma immediately after thawing.
Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C. Transfuse the plasma over 4 hr.
Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D. Hold the transfusion if the client is actively bleeding.
Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
Full Explanation
A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.