A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Request an interpreter of a different sex from the client.

Request a family member or friend to interpret information for the client.

Direct attention toward the interpreter when speaking to the client.

Review the facility policy about the use of an interpreter.

Answer and Explanation

The Correct Answer is D

A. Request an interpreter of a different sex from the client: The interpreter’s sex should ideally match the client’s preference for comfort and privacy, but this is not the first action. The priority is understanding facility policy and proper use of interpreters.

B. Request a family member or friend to interpret information for the client: Using family or friends can lead to miscommunication, breaches of confidentiality, or bias. Professional interpreters are preferred to ensure accurate and complete information.

C. Direct attention toward the interpreter when speaking to the client: When using an interpreter, the nurse should maintain eye contact and direct communication to the client, not the interpreter, to foster rapport and respect.

D. Review the facility policy about the use of an interpreter: Reviewing policy ensures that the nurse follows legal, ethical, and professional guidelines for language access services. This is the appropriate first action before arranging or using an interpreter.

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Correct Answer is C

Explanation

Rationale:

A. Administer ondansetron to the client for nausea: Treating nausea is important for comfort, but it does not address the most urgent risk. Nausea is not immediately life-threatening compared with potential complications from medication overdose.

B. Obtain a blood glucose level: Checking blood glucose can provide useful information, but there is no indication of hypoglycemia or diabetes-related crisis in this scenario. It is not the priority action.

C. Implement seizure precautions for the client: The client has been doubling the bupropion dose, which significantly increases the risk of seizures, especially at doses above the prescribed maximum. Seizure precautions address an immediate life-threatening risk and should be the first intervention.

D. Obtain the client's weight: Monitoring weight is important for assessing nutritional status and the severity of depression, but it is not an immediate safety concern. Life-threatening risks, such as seizures, take priority.

A. Increased creatinine B. Increased calcium C. Increased bicarbonate D. Increased hemoglobin

Correct Answer is A

Explanation

Rationale:

A. Increased creatinine: Chronic kidney disease reduces the kidneys’ ability to filter waste products effectively, causing creatinine to accumulate in the blood. Elevated creatinine is a key indicator of declining renal function and is expected in this condition.

B. Increased calcium: Clients with chronic kidney disease often have decreased calcium levels due to impaired vitamin D activation and phosphate retention. Increased calcium would be unusual unless the client is receiving supplementation.

C. Increased bicarbonate: Metabolic acidosis is common in chronic kidney disease because the kidneys cannot adequately excrete hydrogen ions or reabsorb bicarbonate. This typically results in decreased, not increased, bicarbonate levels in the blood.

D. Increased hemoglobin: Anemia frequently occurs in chronic kidney disease due to reduced erythropoietin production by the kidneys. This leads to lower hemoglobin levels, so an increase would not be expected unless treated with erythropoiesis-stimulating agents.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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