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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A bone fragment has injured the nerve supply in the area is not the best response by the nurse. This may be a possible complication of a fracture, but it does not explain the mechanism of compartment syndrome. Compartment syndrome is a condition where the pressure within a closed space (such as a muscle compartment) exceeds the perfusion pressure and causes ischemia and necrosis of the tissues. A bone fragment may damage the nerve, but it does not cause increased pressure in the compartment.
Choice B reason: An injured artery causes impaired arterial perfusion through the compartment is not the best response by the nurse. This may be a possible cause of compartment syndrome, but it is not the most common one. Compartment syndrome is more often caused by venous obstruction than arterial obstruction. An injured artery may reduce the blood flow to the compartment, but it does not cause increased pressure in the compartment.
Choice C reason: Bleeding and swelling cause increased pressure in an area that cannot expand is the best response by the nurse. This is the most common cause of compartment syndrome and explains the pathophysiology of the condition. Bleeding and swelling are the result of inflammation and tissue injury that occur after a fracture. They increase the volume of fluid in the compartment, which cannot expand due to the rigid fascia that surrounds it. This leads to increased pressure in the compartment, which compresses the blood vessels, nerves, and muscles and causes ischemia and necrosis of the tissues.
Choice D reason: The fascia expands with injury, causing pressure on underlying nerves and muscles is not the best response by the nurse. This is not a correct statement, as the fascia does not expand with injury. The fascia is a tough connective tissue that encloses the muscle compartments and limits their expansion. The fascia is part of the problem, not the cause, of compartment syndrome. The fascia prevents the compartment from accommodating the increased volume of fluid and causes increased pressure in the compartment.
Correct Answer is C
Explanation
Choice A reason: Purulent exudate is a thick, yellowgreen, or brown pus that indicates infection. It is not bloodtinged and does not drip from the wound.
Choice B reason: Serous exudate is a clear, thin, and watery fluid that is normal in the inflammatory stage of wound healing. It does not contain blood cells and is not red in color.
Choice C reason: Serosanguineous exudate is a pink or red fluid that contains both serum and blood. It is common in the proliferative stage of wound healing and may drip from the wound due to increased capillary permeability.
Choice D reason: Sanguineous exudate is a bright or dark red fluid that consists mostly of blood. It indicates active bleeding and is usually seen in traumatic or surgical wounds. It is not diluted with serum and is more viscous than serosanguineous exudate.
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