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.
Have the client's child translate.
Ask a nursing student who speaks the same language as the client to translate.
Request a female interpreter through the facility.
The Correct Answer is D
Choice A reason:
Allow the client's partner to translate. While the partner may be well-intentioned, using a family member or friend as an ad-hoc interpreter can compromise the confidentiality of the information and may not accurately convey the client's medical concerns.
Choice B reason:
Have the client's child translate. Relying on a child to translate sensitive medical information is inappropriate, as it may burden the child and may lead to potential misunderstandings or omissions in communication.
Choice C reason:
Ask a nursing student who speaks the same language as the client to translate. Although a nursing student who speaks the same language as the client may be able to assist, using a professional interpreter is the preferred option. Professional interpreters have specific training in medical terminology and communication, ensuring the most accurate and effective exchange of information.
Choice D reason:
Using a professional interpreter is essential in situations where the healthcare provider and the client do not speak the same language. It ensures accurate communication, maintains confidentiality, and prevents misunderstandings. In this scenario, the nurse should request an interpreter who is proficient in the client's language to assist with the admission process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
The correct answer is choice b. Performing indwelling urinary catheter care.
Choice A rationale:
Changing the appliance on a new colostomy is a complex task that requires assessment and education, which should be performed by a registered nurse (RN) or a licensed practical nurse (LPN).
Choice B rationale:
Performing indwelling urinary catheter care is a routine task that can be delegated to an assistive personnel (AP) as it involves basic hygiene and maintenance.
Choice C rationale:
Demonstrating how to use an incentive spirometer involves patient education and assessment of the patient’s technique, which should be done by an RN or LPN.
Choice D rationale:
Measuring the depth of a stage 3 pressure injury requires assessment skills and clinical judgment, which are beyond the scope of practice for an AP. This task should be performed by an RN or LPN.
Correct Answer is D
Explanation
The correct answer is D. Muscle pain is a sign of rhabdomyolysis, a rare but serious condition that can occur with statin use and can lead to kidney failure. The nurse should instruct the client to report any muscle pain, weakness, or tenderness to the provider immediately.
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