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.

Answer and Explanation

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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","F"]

Explanation

The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.

They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.

The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.

The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.

The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.

The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.

A. Ensure the client swallows each dose of medication. B. Limit the personal toiletries in the client's room to cologne. C. Keep the client's door shut when they are in the room. D. Observe the client's behavior every 2 hr.

Correct Answer is A

Explanation

The correct answer is A.

Ensure the client swallows each dose of medication. A client who recently attempted suicide is at high risk of another suicide attempt and needs closemonitoring and supervision. The nurse should ensure that the client swallows each dose of medication to prevent hoarding or overdosing on pills. The nurse should also remove any potential means of self-harm from the client's room, such as sharp objects, belts, cords, or cologne that contains alcohol. The nurse should keep the client's door open or use a window to observe them at all times, not just every 2 hours.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","F"]

Explanation

A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is caring for a client who has a prescription for warfarin. Which of the following laboratory tests should the nurse monitor?

A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

A nurse is caring for a client who is to begin chemotherapy. The client asks the nurse about managing hair loss. Which of the following responses should the nurse make?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?