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.

Nursing Test Bank

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Correct Answer is B

Explanation

A) Vomiting: While nausea and vomiting can occur during pregnancy, they are not specific complications related to amniocentesis. The nurse should focus on more serious potential complications following the procedure.

B) Contractions: This is the most relevant complication to monitor for after an amniocentesis. The procedure can stimulate uterine contractions, which may lead to preterm labor, especially at 33 weeks of gestation. Monitoring for contractions is essential to ensure the safety of both the mother and the fetus.

C) Hypertension: Hypertension is not a direct complication associated with amniocentesis. While the stress of the procedure may affect blood pressure, it is not a typical monitoring concern immediately following the procedure.

D) Epigastric pain: Although epigastric pain can occur in pregnancy, it is not a specific complication of amniocentesis. Monitoring should focus on uterine activity and signs of labor rather than general abdominal pain unless it is severe or accompanied by other concerning symptoms.

A. Kaposi's sarcoma lesions B. Hemangiomas C. Psoriasis D. Raised facial rash

Correct Answer is D

Explanation

A) Kaposi's sarcoma lesions: Kaposi's sarcoma is a cancer that commonly appears in individuals with immunocompromised states, such as those with HIV/AIDS. It is not associated with systemic lupus erythematosus (SLE). Therefore, finding Kaposi's sarcoma lesions would not be expected in a client with SLE.

B) Hemangiomas: Hemangiomas are benign vascular tumors typically seen in infants and children. While they can occur in various skin conditions, they are not characteristic of systemic lupus erythematosus. Thus, finding hemangiomas would not be relevant in this context.

C) Psoriasis: Psoriasis is a chronic autoimmune condition that causes red, scaly patches on the skin. While both psoriasis and lupus are autoimmune disorders, the specific skin manifestations of lupus differ from those of psoriasis. Therefore, a nurse would not expect to find psoriasis in a client with systemic lupus erythematosus.

D) Raised facial rash: A raised facial rash, often described as a "butterfly rash," is a classic manifestation of systemic lupus erythematosus. This rash typically appears across the cheeks and nose and is associated with photosensitivity, making it a key finding when assessing clients with SLE. Thus, the presence of a raised facial rash is an expected and significant finding in this condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Correct Answer is B

Explanation

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?

A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag, causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is providing discharge teaching for a client who has a new implantable cardioverter defibrillator (ICD). Which of the following client statements demonstrates understanding of the teaching?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?