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 C

Explanation

A. Volunteer to provide an inservice about infection control.While providing an inservice about infection control is important, it is not the immediate priority. The nurse needs to address the current situation to prevent potential contamination and infection spread.

B. Speak with the AP when he exits the room about the appropriate protocol.Speaking with the AP about the appropriate protocol is necessary, but it should be done after ensuring the immediate safety of the client and others. Delaying action could result in exposure to infectious agents.

C. Provide the appropriate PPE to the AP.This action addresses the immediate risk of infection transmission. By providing the appropriate PPE, the nurse ensures that the AP can safely continue their duties without putting themselves or the client at risk.

D. Notify the charge nurse about the AP's need for training.Notifying the charge nurse is important for long-term improvement, but it does not address the immediate risk. The nurse must first ensure that the AP is properly equipped to handle the current situation safely.

A. Drowsiness. B. Jaundice. C. Flushed pink cheeks. D. Tachycardia.

Correct Answer is D

Explanation

Choice A rationale:

Drowsiness is not a typical finding associated with hypoxia. Hypoxia often leads to increased alertness and anxiety as the body tries to compensate for the lack of oxygen. Drowsiness might be seen in severe cases of hypoxia, but it's not a consistent finding.

Choice B rationale:

Jaundice is not directly related to hypoxia. Jaundice is usually caused by elevated bilirubin levels due to liver dysfunction or other underlying issues. It is not a primary manifestation of hypoxia.

Choice C rationale:

Flushed pink cheeks can be an indicator of increased blood flow to the skin, which might occur as the body tries to compensate for hypoxia. However, this finding is not as consistent or specific as tachycardia in cases of hypoxia.

Choice D rationale:

Tachycardia, or an abnormally rapid heart rate, is a common physiological response to hypoxia. The body attempts to deliver more oxygen to tissues by increasing the heart rate. This compensatory mechanism helps maintain tissue perfusion in the face of reduced oxygen levels.

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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

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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