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: Fistula is a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin. Fistula can occur as a result of infection, inflammation, trauma, surgery, or congenital defect. Fistula can cause pain, bleeding, discharge, or leakage of fluids or gases from the affected organs or tissues. Fistula can also increase the risk of infection, obstruction, or perforation of the involved organs or tissues.
Choice B reason: Hemorrhage is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an excessive or uncontrolled bleeding from the wound site. Hemorrhage can occur as a result of trauma, surgery, infection, or coagulation disorder. Hemorrhage can cause pain, swelling, bruising, or shock at the wound site. Hemorrhage can also lead to blood loss, anemia, or hypovolemia.
Choice C reason: Infection is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is an invasion and multiplication of microorganisms in the wound site. Infection can occur as a result of contamination, poor hygiene, or impaired immunity. Infection can cause pain, redness, warmth, swelling, or pus at the wound site. Infection can also trigger inflammation, fever, or systemic illness.
Choice D reason: Evisceration is not a complication of wound healing that is an abnormal passage that connects two body cavities or a cavity and the skin, but rather a complication of wound healing that is a protrusion of internal organs or tissues through the wound site. Evisceration can occur as a result of dehiscence, which is a separation or splitting open of the wound edges. Evisceration can cause pain, bleeding, or shock at the wound site. Evisceration can also expose the internal organs or tissues to injury, infection, or necrosis.
Correct Answer is A
Explanation
Choice A reason: A client with leukemia is a susceptible host most at risk for infection. Leukemia is a type of cancer that affects the blood cells, especially the white blood cells, which are responsible for fighting infections. Leukemia causes the production of abnormal and immature white blood cells that cannot function properly and crowd out the normal ones. This leads to a condition called leukopenia, which is a low level of white blood cells. Leukopenia makes the client more vulnerable to infection by reducing the immune system's ability to defend against pathogens.
Choice B reason: A child who is immunized is not a susceptible host most at risk for infection. Immunization is a process that stimulates the immune system to produce antibodies against a specific disease. Immunization protects the child from getting infected by the disease or reduces the severity of the infection if it occurs. Immunization also prevents the spread of the disease to other people who are not immunized or who are immunocompromised.
Choice C reason: A 60yearold client is not a susceptible host most at risk for infection. Age is a factor that may influence the susceptibility to infection, but it is not the most important one. Older adults may have a weaker immune system due to aging, chronic diseases, or medications, but they may also have a stronger immune memory due to previous exposure to pathogens. The risk of infection in older adults depends on their overall health status, lifestyle, and preventive measures.
Choice D reason: A hospitalized 35yearold client is not a susceptible host most at risk for infection. Hospitalization is a factor that may increase the exposure to infection, but it is not the most significant one. Hospitalized clients may encounter various sources of infection, such as health care workers, other clients, medical equipment, or invasive procedures, but they may also receive adequate infection control measures, such as hand hygiene, isolation, sterilization, or prophylaxis. The risk of infection in hospitalized clients depends on their diagnosis, treatment, and compliance.
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