The nurse is caring for a patient who is a recent immigrant and has limited English proficiency. Which of the following is the best action the nurse should take?

Correct Answer: C

Rationale: The correct answer is C: Use a professional interpreter or translation services to communicate effectively. This is the best action because it ensures accurate communication and understanding between the nurse and the patient. Professional interpreters are trained to accurately convey information while respecting cultural nuances. Explanation for why the other choices are incorrect: A: Using medical jargon can confuse the patient further and hinder effective communication. B: Speaking loudly and slowly can come across as patronizing and does not address the language barrier. D: Relying on the patient's family for translation can lead to miscommunication or breaches of patient confidentiality.

Correct Answer: A

Rationale: The correct answer is A: Inspecting feet daily for signs of injury. This is crucial in diabetic neuropathy to prevent complications such as infections and ulcers. By inspecting the feet daily, the patient can identify any injuries early and seek prompt treatment. Exercising (choice B) is important, but not the top priority. Taking pain medication (choice C) only addresses symptoms, not the root cause. Increasing protein intake (choice D) may be beneficial for healing, but foot inspection is more directly related to preventing complications in diabetic neuropathy.

Correct Answer: A

Rationale: Step-by-step rationale for choosing Albuterol as the correct answer: 1. Albuterol is a rapid-acting bronchodilator that provides immediate relief by relaxing the airway muscles during asthma exacerbation. 2. It is the first-line medication recommended by guidelines for acute asthma attacks due to its quick onset of action. 3. Albuterol helps in opening the airways, improving airflow, and relieving symptoms like shortness of breath and wheezing. 4. Epinephrine is not the first choice for asthma exacerbation as it can have more systemic side effects. 5. Levalbuterol is a similar medication to Albuterol but may not be as widely available or cost-effective. 6. IV corticosteroids are important for long-term control but take longer to show effects, making them less suitable as the initial treatment for acute exacerbation.

Correct Answer: C

Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.

Correct Answer: A

Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.

Correct Answer: B

Rationale: Acyclovir is a nucleoside analog antiviral drug that is specifically effective against herpes simplex virus (HSV) types 1 and 2, as well as varicella-zoster virus (VZV). The drug works by inhibiting viral DNA synthesis. HSV and VZV are both members of the herpes virus family, and acyclovir is most commonly prescribed for infections caused by these viruses. Therefore, the correct answer is B. Choice A (HIV) is incorrect because acyclovir is not effective against HIV. Choice C (CMV) is incorrect because acyclovir is less effective against cytomegalovirus (CMV) compared to HSV and VZV. Choice D (influenza A viruses) is incorrect because acyclovir is not indicated for the treatment of influenza viruses.

Correct Answer: A

Rationale: The correct answer is A because avoiding environmental allergens and cold air can help prevent asthma attacks. This shows the patient understands the importance of managing triggers. Choice B is incorrect because over-the-counter medications may not be sufficient for asthma management. Choice C is incorrect because smoking can worsen asthma symptoms. Choice D is incorrect because using the inhaler only when feeling short of breath is not a proactive approach to managing asthma triggers.

Correct Answer: C

Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.

Correct Answer: C

Rationale: The correct answer is C because the clothing of a trauma client could potentially be considered evidence with legal implications. Preserving the bloodstains or tears on the clothing maintains the integrity of the evidence for forensic investigation or legal proceedings. Disrupting the bloodstains or tears could compromise the evidence and hinder any potential investigation or legal case. Choices A, B, and D are incorrect because the primary concern in this scenario is the legal implications and preservation of evidence, not ownership, repair, salvage, or minimizing trauma to family members.