A nurse is reinforcing discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse document in the client's medical record to ensure the language needs are met?
Nurse addressing the client directly while the interpreter is present.
Nurse asking the client for questions at the end of the instructions.
Staff member serving as an interpreter for the client.
Family member acting as an interpreter for the client.
The Correct Answer is A
Rationale:
A. Nurse addressing the client directly while the interpreter is present: This demonstrates culturally competent and client-centered care. Documenting that the nurse communicated directly with the client through a qualified interpreter shows appropriate use of interpretation services and respect for the client's autonomy.
B. Nurse asking the client for questions at the end of the instructions: While this is good practice, it does not specifically demonstrate that the client's language needs were addressed. Without interpreter documentation there’s no assurance the client understood the information.
C. Staff member serving as an interpreter for the client: Unless the staff member is a certified medical interpreter, using them for interpretation may result in miscommunication and is not best practice. Documentation should reflect use of trained professionals.
D. Family member acting as an interpreter for the client: Family members should not be used for interpretation due to risks of bias, inaccuracies, and privacy violations. Professional interpreters are necessary to ensure accurate, safe, and confidential communication.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Gown: The gown should be removed after the gloves because it may be contaminated but has less direct contact with infectious material. Removing it after gloves helps reduce the risk of spreading pathogens from the hands to the clothing or environment.
B. Mask: The mask is usually removed last to prevent inhalation of airborne or droplet contaminants during PPE removal. Premature removal may expose the nurse to infectious particles still present in the surrounding air.
C. Eyewear: Goggles or face shields should be removed after gloves to avoid contamination of the face during removal. Touching the eyewear with potentially contaminated gloves could transfer pathogens close to the eyes or face.
D. Gloves: Gloves are the most contaminated PPE item due to direct patient contact and should be removed first. This limits the risk of transferring pathogens from the gloves to other PPE or surfaces during the removal process.
Correct Answer is D
Explanation
Rationale:
A. Measles, mumps, and rubella (MMR): MMR is a live attenuated vaccine and is contraindicated during pregnancy due to the risk of fetal harm. It should be given at least one month prior to conception or postpartum if immunity is needed.
B. Varicella (VAR): Like MMR, the varicella vaccine is live and should not be administered during pregnancy. Pregnant individuals without evidence of immunity should receive it postpartum to protect against future infections.
C. Tetanus diphtheria and pertussis (Tdap): Tdap is recommended during each pregnancy but typically between 27 and 36 weeks of gestation to maximize passive antibody transfer to the fetus. At 16 weeks, it would not yet be indicated.
D. Inactivated influenza (IV): The inactivated flu vaccine is recommended for all pregnant clients during flu season, regardless of the trimester. It protects both the pregnant individual and the fetus from complications related to influenza infection.
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