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 A
Explanation
Rationale:
A. Support the extremity above and below each joint during the exercises: Supporting the limb properly prevents strain on the joints and muscles, reduces pain, and helps maintain proper alignment during passive range-of-motion exercises.
B. Repeat each exercise movement 10 times: Repetitions vary depending on the client’s condition and tolerance. A general guideline is 5 to 10 repetitions, but individualized assessment is important to avoid fatigue or injury.
C. Move each joint just past the point of resistance: Moving a joint beyond the point of resistance can cause pain, injury, or dislocation. Movements should be gentle and stop when resistance or discomfort is felt.
D. Position the bed at mid-thigh level: Bed height should be adjusted for caregiver ergonomics to prevent injury, but "mid-thigh level" is not a standard recommendation for performing range-of-motion exercises.
Correct Answer is ["A","C"]
Explanation
Rationale:
• Naloxone: The client received fentanyl and is now showing signs of opioid-induced respiratory depression. Respiratory rate has decreased to 10/min and oxygen saturation to 87%. Naloxone will reverse the opioid’s effects and restore adequate respiratory effort.
• An additional dose of propofol: The client’s level of sedation is already too deep, as shown by low respiratory rate and blood pressure. Additional propofol would worsen central nervous system depression. It may cause complete apnea or cardiac compromise in this situation.
• Oxygen 10 L/min via face mask: The current oxygen flow via nasal cannula is insufficient given the client's low oxygen saturation. A face mask delivers higher oxygen concentration and flow. This is critical to correct hypoxia until the cause is reversed.
• Acetaminophen: There is no fever or current complaint of pain requiring antipyretics or analgesics. Administering acetaminophen now would not address the acute respiratory issue. It would delay more urgent and appropriate interventions.
• An additional dose of fentanyl: Administering more opioid would increase the risk of further respiratory depression. The client is already showing hypoventilation and declining oxygenation. More fentanyl would worsen sedation and endanger airway and breathing.
• Propranolol: The client is already hypotensive with a BP of 80/51 mm Hg and a heart rate of 68/min. Giving a beta blocker could severely depress cardiac output. This would increase the risk of organ hypoperfusion and cardiac arrest.
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