A nurse is planning to provide preoperative teaching to a client who speaks a different language than the nurse. Which of the following actions should the nurse take?
Ask a family member to translate the information for the client.
Use a telephone medical interpreter service.
Request an assistive personnel who speaks the client’s language to translate.
Direct all information to the person who is translating for the client.
The Correct Answer is B
Choice A reason: Asking a family member to translate is inappropriate because family members may lack medical knowledge, misinterpret information, or withhold sensitive details. This compromises accuracy and confidentiality.
Choice B reason: Using a telephone medical interpreter service ensures accurate, professional translation of medical information. Medical interpreters are trained to convey complex terminology and maintain confidentiality, making this the correct action.
Choice C reason: Assistive personnel may not be trained in medical interpretation. Even if they speak the language, they may misinterpret medical terminology, leading to errors in client understanding.
Choice D reason: The nurse should direct all information to the client, not the interpreter. The interpreter’s role is to facilitate communication, but maintaining eye contact and addressing the client directly preserves therapeutic rapport and respect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Documenting observation every 15 min is correct. Frequent monitoring ensures client safety, assesses circulation, skin integrity, and psychological well-being, and prevents complications such as injury or restricted blood flow.
Choice B reason: The provider should assess the client much sooner than 48 hr. Restraint use requires frequent reassessment, typically within 24 hr, to determine ongoing necessity. Waiting 48 hr is unsafe.
Choice C reason: The prescription for a restraint should be renewed every 24 hr, not 6 hr. Restraints require daily provider review to ensure they remain necessary and appropriate.
Choice D reason: Range-of-motion exercises should be performed every 2 hr, not every 12 hr. Frequent ROM prevents contractures, maintains circulation, and reduces complications from immobility.
Correct Answer is D
Explanation
Choice A reason: Clothing the newborn in light cotton is inappropriate during phototherapy. The infant should be undressed except for a diaper to maximize skin exposure to the light. Covering the skin reduces the effectiveness of phototherapy.
Choice B reason: Checking the newborn’s temperature every 8 hours is insufficient. Infants under phototherapy are at risk for temperature instability, so monitoring should occur at least every 2–4 hours. Waiting 8 hours could miss early signs of hypothermia or hyperthermia.
Choice C reason: Administering water between feedings is contraindicated. Newborns should not receive water because it can cause electrolyte imbalance and interfere with nutrition. Adequate hydration should be maintained through frequent breastfeeding or formula feeding.
Choice D reason: Placing the newborn 45 cm (18 in) from the light source is correct. This distance ensures effective exposure while preventing overheating or burns. Proper positioning is essential for safe and effective phototherapy.
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