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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate toxicity, but it should be given after stopping the infusion and assessing the client’s respiratory status. Immediate discontinuation takes priority.

B. Discontinue the infusion: Difficulty breathing indicates a potential magnesium sulfate toxicity or respiratory depression, which is a life-threatening emergency. The first action is to stop the infusion to prevent further accumulation.

C. Assess the fetal heart rate: Monitoring the fetus is important, but maternal safety takes priority over fetal assessment in a potential toxic reaction. Stabilizing the mother comes first.

D. Obtain the client's magnesium level: Lab assessment is useful for confirming toxicity, but it should not delay immediate intervention. Stopping the infusion takes precedence over obtaining levels.

A. A client who is taking warfarin and has started to breastfeed. B. A client who is taking bumetanide and reports an increase in urinary frequency. C. A client who received a Mantoux test 48 hr ago and has an induration. D. A client who is scheduled for a colonoscopy and is taking sodium phosphate.

Correct Answer is A

Explanation

A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.

B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.

C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.

D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The client reports that she is experiencing difficulty breathing. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving peritoneal dialysis for manifestations of peritonitis. Which of the following findings should the nurse identify as the first indication of peritonitis?

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