A nurse is reinforcing teaching about self-care with a client who has pelvic inflammatory disease. The client does not speak English. Which of the following actions by the nurse is appropriate?
Ask the client's English-speaking family member to translate.
Use a translation dictionary to reinforce the teaching.
Seek assistance from a facility-approved interpreter.
Ask an assistive personnel (AP) who speaks the client's language to serve as an interpreter.
The Correct Answer is C
Choice A: Ask the client's English-speaking family member to translate. This action is not appropriate because it may compromise the accuracy and confidentiality of the information. The family member may not have sufficient medical knowledge or vocabulary to translate correctly or may omit or alter some details due to personal bias or embarrassment.
Choice B: Use a translation dictionary to reinforce the teaching. This action is not appropriate because it may be time-consuming and ineffective. The translation dictionary may not have all the relevant terms or phrases or may provide inaccurate or ambiguous translations. The nurse may also lose the client's attention or interest by relying on the dictionary.
Choice C: Seek assistance from a facility-approved interpreter. This action is appropriate because it ensures the quality and clarity of the communication. The facility-approved interpreter is a professional who has the skills and training to provide accurate and unbiased translation of the information. The interpreter can also facilitate the interaction and feedback between the nurse and the client.
Choice D: Ask an assistive personnel (AP) who speaks the client's language to serve as an interpreter. This action is not appropriate because it may violate the scope of practice and ethical standards of the AP. The AP may not have the qualifications or authority to provide interpretation services or may have a conflict of interest or role confusion with the client. The AP may also have other duties or responsibilities that may interfere with the interpretation process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
- To find out how many gtt/min to set for a manual IV infusion, we need to use this formula: gtt/min = (mL/hr x drop factor) / 60
- In this formula, mL/hr is the rate of infusion in milliliters per hour, drop factor is the number of drops per milliliter for a specific IV tubing, and 60 is the number of minutes in an hour.
- We plug in the given values into this formula: gtt/min = (120 mL/hr x 10 gtt/mL) / 60
- We simplify and solve this equation: gtt/min = (1200 gtt/hr) / 60
- We divide both sides by 60: gtt/min = 20 gtt/hr
- We round off to the nearest whole number: gtt/min = **20**
- We add a leading zero if needed: gtt/min = **20**
- We do not add a trailing zero: gtt/min = **20**
Correct Answer is B
Explanation
Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.
Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.
Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.
Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.
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