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?

Ask a nursing student who speaks the same language as the client to translate.

Allow the client's partner to translate.

Request a female interpreter through the facility.

Have the client's child translate.

Answer and Explanation

The Correct Answer is C

A. Ask a nursing student who speaks the same language as the client to translate: This is not appropriate, as the nursing student may not be trained in medical terminology or confidentiality, which could lead to miscommunication and potential breaches of privacy.

B. Allow the client's partner to translate: While the partner may understand the language, this approach can create conflicts of interest, and they may not be able to convey the full medical context or sensitive information accurately.

C. Request a female interpreter through the facility: This is the best action. Using a trained, professional interpreter ensures that the communication is accurate and confidential, allowing the nurse to gather necessary admission data effectively while respecting the client's comfort and cultural needs.

D. Have the client's child translate: It is not appropriate to involve a child in medical discussions, as they may not fully understand the context or terminology and could feel overwhelmed by the responsibility.

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Correct Answer is C

Explanation

A. Obtain a trough level 30 min after the medication infusion: Trough levels should be drawn just before the next dose, not 30 minutes after the infusion. This timing ensures accurate measurement of the drug’s lowest concentration in the bloodstream.

B. Inject 1% lidocaine prior to each dose: While lidocaine may help reduce discomfort at the injection site, it is not a standard practice for all patients receiving vancomycin and does not address the risk of systemic adverse reactions.

C. Give the dose over 60 min: Administering vancomycin over a period of at least 60 minutes is essential to minimize the risk of infusion-related reactions, such as "red man syndrome," which can occur if the drug is infused too quickly.

D. Administer the medication undiluted: Vancomycin should always be diluted according to guidelines before administration to reduce the risk of irritation to the veins and potential adverse reactions. Administering undiluted increases the risk of complications.

A. Plans for a check of the client's fingerstick glucose level every 6 hr B. Schedules a bag and tubing change for 24 hr after the start of the infusion C. Uses the TPN IV tubing to administer the client's next dose of antibiotics D. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved

Correct Answer is C

Explanation

A. Plans for a check of the client's fingerstick glucose level every 6 hr: Monitoring blood glucose levels is essential for clients receiving TPN due to the risk of hyperglycemia. Checking glucose every 6 hours is a standard practice that helps ensure appropriate glycemic control, so this action is appropriate.

B. Schedules a bag and tubing change for 24 hr after the start of the infusion: It is standard practice to change the TPN bag and tubing every 24 hours to reduce the risk of infection and maintain sterility. This timing aligns with best practices for TPN administration, indicating no need for intervention.

C. Uses the TPN IV tubing to administer the client's next dose of antibiotics: Using the TPN line for additional medications, such as antibiotics, can lead to complications like incompatible drug interactions or infection. TPN should ideally be delivered through a dedicated line to prevent these risks, which necessitates intervention from the supervising nurse.

D. Gradually increases the TPN infusion rate each hour until the prescribed rate is achieved: Gradual escalation of the TPN infusion rate is important to prevent complications such as hyperglycemia. This action is appropriate, as it allows the body to adapt to the increased caloric intake safely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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