The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Request a family member to remain with the client.

Ask for the support of one of the client’s friends.

Use drawings that are universal for all cultures.

Obtain a staff member who is a bilingual interpreter.

Answer and Explanation

The Correct Answer is D

Choice A: Request a family member to remain with the client is not the best intervention because it may compromise the confidentiality and accuracy of the assessment. The family member may not be able to translate correctly or may influence the client’s responses.
Choice B: Ask for the support of one of the client’s friends is not the best intervention because it may also violate the privacy and validity of the assessment. The friend may not be qualified or willing to translate or may have a conflict of interest with the client.
Choice C: Use drawings that are universal for all cultures is not the best intervention because it may not be sufficient or appropriate for the assessment. Drawings may not convey all the information needed or may be misinterpreted by the client.
Choice D: Obtain a staff member who is a bilingual interpreter is the best intervention because it facilitates the communication and understanding between the nurse and the client. The interpreter should be trained and certified in medical terminology and cultural sensitivity.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is incorrect because raising the head of the bed to 60 degrees can help prevent aspiration by using gravity to keep food in the stomach and away from the lungs.

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is correct because allowing 30 minutes of rest before feeding can increase the risk of aspiration by reducing the client's alertness and coordination. The UAP should feed the client when he or she is awake and responsive.

A. Decrease the flow rate to 1 L/minute. B. Place padding around the cannula tubing. C. Apply lubricant to the cannula tubing. D. Discontinue the use of the nasal cannula.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because decreasing the flow rate to 1 L/minute can compromise the client's oxygenation and worsen hypoxia. The client's oxygen saturation level is below the normal range of 95% to 100%.

Choice B Reason: This is correct because placing padding around the cannula tubing can prevent pressure ulcers and skin breakdown caused by friction and irritation from the tubing.

Choice C Reason: This is incorrect because applying lubricant to the cannula tubing can increase the risk of infection and inflammation of the nasal mucosa. Lubricant should be applied sparingly to the nares only if needed.

Choice D Reason: This is incorrect because discontinuing the use of the nasal cannula can endanger the client's life and cause respiratory failure. The client needs supplemental oxygen to maintain adequate oxygenation.

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The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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