A nurse is interviewing a female client who is Hispanic. The client's husband answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take?

Use an internet webpage translator for the client.

Arrange to complete the assessment with only the client and a translator present.

Ask the client's husband to translate questions and answers for the client.

Ask a male student nurse to translate for the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Using an internet webpage translator might seem convenient, but it can lead to inaccuracies in communication due to language nuances and medical terminology. Direct communication with a human translator is more reliable.

Choice B rationale:

Arranging to complete the assessment with only the client and a translator present is the best option. This approach ensures accurate and confidential communication, allowing the nurse to gather essential information directly from the client without potential bias or misinterpretation from family members.

Choice C rationale:

Asking the client's husband to translate questions and answers for the client can lead to inaccurate or biased information. Additionally, it might not provide a safe environment for the client to openly share her concerns.

Choice D rationale:

Asking a male student nurse to translate for the client does not necessarily address the language barrier adequately. The gender of the translator is not the primary concern here. Ensuring effective communication through a professional translator is more important.

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Correct Answer is B

Explanation

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

A. Explain to the client that he needs the protein in the milk and the beef. B. Allow the AP to deliver the food tray to the client. C. Replace the nonfat milk with apple juice. D. Call the dietary department and ask for a kosher tray.

Correct Answer is D

Explanation

Choice A rationale:

Explaining to the client that he needs the protein in the milk and the beef is not an appropriate action. Understanding and respecting the client's religious and dietary preferences are essential. Orthodox Jewish dietary laws, known as kashrut, prohibit the consumption of certain foods, including the mixing of meat and dairy in the same meal. This response disregards the client's faith-based dietary restrictions.

Choice B rationale:

Allowing the AP to deliver the food tray to the client is not appropriate in this situation. The nurse is responsible for ensuring that the client's dietary needs and preferences are met, especially when there are religious considerations involved. Failing to accommodate the client's dietary requirements could lead to non-compliance and potential harm.

Choice C rationale:

Replacing the nonfat milk with apple juice does not address the client's religious dietary restrictions. While the change may avoid mixing meat and dairy, it still disregards the importance of providing a kosher meal. Kosher dietary laws encompass more than just avoiding meat and dairy combinations. It is important to provide a fully compliant kosher meal.

Choice D rationale:

Calling the dietary department and asking for a kosher tray is the appropriate action. A kosher diet adheres to specific rules and regulations, including the separation of meat and dairy products. To respect the client's faith and dietary needs, the nurse should ensure that the food provided aligns with kosher guidelines. This choice demonstrates cultural sensitivity and ensures the client's well-being.

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A nurse is interviewing a female client who is Hispanic. The client's husband answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Correct Answer is B

Explanation

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to his client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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