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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Give the dose of medication in the infant's bottle: Placing nystatin in a bottle may result in incomplete dosing, as the infant may not consume the full amount. This method also limits the medication's contact time with the affected mucosa, reducing its effectiveness.
B. Educate the caregiver to avoid breastfeeding: Breastfeeding should not be avoided unless the mother has signs of candidiasis on the breast. Instead, both mother and infant should be treated simultaneously if either shows symptoms to prevent reinfection.
C. Administer the medication before the infant's feeding: Administering nystatin before feeding may cause the medication to be washed away by milk, decreasing mucosal contact time. It is generally recommended after feeding to ensure prolonged exposure to the mucosa.
D. Distribute the medication on the infant's oral mucosa: Applying the suspension directly to the affected areas allows the antifungal to coat the mucosa thoroughly, maximizing effectiveness. It is the preferred method to treat oral candidiasis in infants.
Correct Answer is A
Explanation
Rationale:
A. Preeclampsia: Methylergonovine causes vasoconstriction and increases blood pressure, which can be dangerous in clients with preeclampsia. Administering this medication in such cases can elevate the risk of stroke or seizure due to worsening hypertension.
B. An allergy to penicillin: Methylergonovine is not a penicillin-based medication, so a penicillin allergy does not present a known contraindication or concern. Caution is unnecessary unless there is a known allergy to ergot alkaloids.
C. Gestational diabetes mellitus: Methylergonovine does not significantly impact blood glucose levels or insulin sensitivity. Therefore, it can be used safely in clients with gestational diabetes when indicated for hemorrhage control.
D. Cholelithiasis: There is no direct interaction or exacerbation of gallbladder disease with methylergonovine. The medication primarily acts on uterine smooth muscle and vascular tone, not on the biliary system.
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