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Extract:

Liang Tam, 68 years old, was admitted to the hospital with GI bleeding. She arrived to USA from China, as landed immigrant, 3 months ago. Chin speaks Mandarin and little English. Her daughter, Linda Min, speaks fluent English.


Question 1 of 5

To whom will the registered nurse, during the admission interview, collects the information from?

Correct Answer: B

Rationale: An interpreter ensures accurate communication with the patient, respecting her autonomy.

Extract:


Question 2 of 5

At what point in the nurse-client relationship should termination first be addressed?

Correct Answer: C

Rationale: Addressing termination in the orientation phase sets clear expectations for the relationship's duration, ensuring transparency. Waiting until later phases or client initiation is less structured. Coordinated Care

Question 3 of 5

A nurse's aide who had a tuberculosis test planted two days ago has a reddened area 15-mm in diameter. The aide asks the nurse what this means. The nurse understands that the test result is:

Correct Answer: D

Rationale: Redness alone without induration is not significant; a positive TB test requires a raised area ≥10 mm, indicating this is negative.

Question 4 of 5

Following mitral valve replacement surgery a client develops PVC's. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mg/minute. Which finding indicates that the client is experiencing lidocaine toxicity?

Correct Answer: D

Rationale: No measurable voiding in 4 hours. The concern is possible hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys.

Question 5 of 5

The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which of the following flow rates is MOST appropriate?

Correct Answer: A

Rationale: Low-flow oxygen (1–2 L/min via nasal cannula) is appropriate for COPD to maintain oxygenation without suppressing the hypoxic drive. Higher flows (B, C,
D) risk CO2 retention in COPD patients.

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