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?

Have the client's child translate.

Allow the client's partner to translate.

Request a female interpreter through the facility.

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

Answer and Explanation

The Correct Answer is C

A.   Using a child as an interpreter can be inappropriate and may not ensure accurate communication, especially for sensitive topics such as medical history and symptoms.
B.   While involving the client's partner may seem helpful, it may not ensure accurate translation, and the partner may not be proficient in medical terminology.
C.   Requesting a female interpreter through the facility ensures accurate and confidential communication while respecting the client's cultural preferences and privacy.
D.   While asking a nursing student who speaks the same language as the client may seem convenient, it may not ensure accurate translation, and the student may not have the necessary training in medical interpretation.

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Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

A. Obtain a blood specimen for ABG analysis. B. Apply 100% humidified oxygen. C. Obtain a baseline ECG. D. Insert an 18-gauge IV catheter.

Correct Answer is B

Explanation

A. Obtain a blood specimen for ABG analysis. Important, but not the first action.

B. In a client with burn injuries experiencing signs of airway compromise (drooling, hoarseness), the first action should be to ensure adequate oxygenation. Applying 100% humidified oxygen can help manage potential airway edema.
C. Obtain a baseline ECG. Necessary for monitoring but secondary to securing the airway.
D. Insert an 18-gauge IV catheter. Essential for fluid resuscitation and medication administration, but after ensuring adequate oxygenation.

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Naxlex Comprehensive Predictor Exams

A nurse observes a client on the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?

A nurse is caring for a client who is recovering from a cerebrovascular accident in a rehabilitation facility. The client tells the nurse, "I am sick of being in here, and I want to go home." Which of the following responses should the nurse make?

A charge nurse is concerned about a recent increase in facility-acquired catheter Infections. Which of the following actions should the nurse take first?

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A nurse is teaching a client about family planning using the basal body temperature method. Which of the following Instructions should the nurse include in the teaching?

A nurse is caring for a client at a clinic. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown due to dropdown.

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