A client arrives speaking only Spanish. What is the priority nursing intervention?
Call the chaplain for support
Verify the reason for admission
Request a medical interpreter
Give the client a tour of the unit
The Correct Answer is C
Choice A reason: Calling the chaplain for support is not the priority nursing intervention for a client who speaks only Spanish. The chaplain may not be able to communicate with the client or understand their needs. This choice does not address the language barrier or the client's reason for admission.
Choice B reason: Verifying the reason for admission is an important nursing intervention, but it is not the priority for a client who speaks only Spanish. The nurse cannot verify the reason for admission without communicating with the client or their family. This choice does not address the language barrier or the client's safety.
Choice C reason: Requesting a medical interpreter is the priority nursing intervention for a client who speaks only Spanish. The medical interpreter can facilitate communication between the nurse and the client, and help the nurse assess the client's condition, reason for admission, and needs. This choice addresses the language barrier and the client's safety.
Choice D reason: Giving the client a tour of the unit is not the priority nursing intervention for a client who speaks only Spanish. The client may not understand the tour or the information given by the nurse. This choice does not address the language barrier or the client's reason for admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Wearing a gown is the correct answer, because it is the appropriate PPE for contact precautions, which are required for clients who have MRSA. MRSA is a type of bacteria that is resistant to many antibiotics and can cause serious infections in the skin, blood, lungs, or other organs. MRSA can be transmitted by direct or indirect contact with the infected wound or contaminated surfaces. Wearing a gown can protect the nurse's clothing and skin from exposure to MRSA.
Choice B reason: Wearing sterile gloves is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Sterile gloves are used for sterile procedures, such as inserting a catheter or changing a dressing, not for routine assessments, such as checking the pulse. Wearing sterile gloves can be wasteful and unnecessary, and it does not provide adequate protection from MRSA.
Choice C reason: Wearing a PAPR mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. PAPR stands for powered airpurifying respirator, and it is a type of mask that filters the air and provides positive pressure to the wearer. PAPR masks are used for airborne precautions, which are required for clients who have diseases that can be spread through the air, such as tuberculosis or measles, not for clients who have MRSA.
Choice D reason: Wearing a surgical mask is not the correct answer, because it is not the appropriate PPE for contact precautions, which are required for clients who have MRSA. Surgical masks are used for droplet precautions, which are required for clients who have diseases that can be spread through respiratory droplets, such as influenza or pertussis, not for clients who have MRSA.
Correct Answer is A
Explanation
Choice A reason: Stage 4 is the remodeling stage of bone healing, which occurs from 6 to 12 weeks after the fracture. In this stage, the callus, which is a mass of fibrous tissue and cartilage that forms around the fracture site, is gradually resorbed and replaced by mature bone. The bone becomes stronger and more compact and regains its original shape and function.
Choice B reason: Stage 3 is the callus formation stage of bone healing, which occurs from 2 to 6 weeks after the fracture. In this stage, the granulation tissue, which is a soft tissue that fills the fracture gap, is replaced by a callus that bridges the fracture ends. The callus is composed of fibroblasts, chondroblasts, and osteoblasts that produce collagen, cartilage, and bone matrix. The callus stabilizes the fracture and prepares it for remodeling.
Choice C reason: Stage 5 is not a valid stage of bone healing. There are only four stages of bone healing: stage 1 is the inflammatory stage, stage 2 is the reparative stage, stage 3 is the callus formation stage, and stage 4 is the remodeling stage.
Choice D reason: Stage 1 is the inflammatory stage of bone healing, which occurs from the time of the fracture to 3 to 5 days after the fracture. In this stage, the blood vessels around the fracture site are ruptured and form a hematoma, which is a blood clot that surrounds the fracture ends. The hematoma triggers an inflammatory response that involves the release of cytokines, growth factors, and inflammatory cells that initiate the healing process. The hematoma also provides a scaffold for the granulation tissue to grow.
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