A nurse is admitting a client who speaks a different language than the nurse.
Which of the following actions should the nurse take?
Telephone the interpreter that is designated for the facility to interpret the information.
Call a nursing colleague who speaks the same language as the client to interpret the information.
Ask the client's partner to interpret the information.
Use an electronic translating service from the internet to interpret the information.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Health education involves providing information and knowledge to clients about their health, which is essential but doesn't directly relate to the nurse's action of blood pressure screening. This choice is less appropriate in this context.
Choice B rationale:
Health promotion encompasses actions that aim to enhance an individual's well-being and prevent illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a key component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.
Choice C rationale:
Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's essential, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.
Choice D rationale:
Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.
Choice B rationale:
Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.
Choice C rationale:
Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.
Choice D rationale:
Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
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