A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?
Allow the client's partner to translate.
Ask a nursing student who speaks the same language as the client to translate.
Have the client's child translate.
Request a female interpreter through the facility.
The Correct Answer is D
A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.
C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.
D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. "Place a pillow under your knees while in bed.": Elevating the knees with a pillow can compress blood vessels and restrict circulation, increasing the risk of venous stasis and deep vein thrombosis.
B. "Participate in range-of-motion exercises.": Performing range-of-motion exercises promotes blood flow in the extremities, prevents venous stasis, and reduces the risk of complications such as deep vein thrombosis, supporting postoperative circulation.
C. "Remain on bed rest for 24 hours following the procedure.": Prolonged immobility can impair circulation and increase the risk of blood clots. Early ambulation and movement are encouraged unless contraindicated by the provider.
D. "Use an incentive spirometer every hour”: While using an incentive spirometer is important for preventing respiratory complications, it primarily promotes lung expansion and does not directly enhance circulation.
Correct Answer is ["A","B","C","E"]
Explanation
A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.
B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.
C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.
D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).
E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).
F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.
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