A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. The nurse speaks a different language than the client. The client's partner and 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's admission data?

Ask a nursing student who speaks the same language as the client to translate.

Allow the client's partner to translate.

Request a female interpreter through the facility.

Have the client's child translate.

Answer and Explanation

The Correct Answer is C

A. Ask a nursing student who speaks the same language as the client to translate: This is not appropriate, as the nursing student may not be trained in medical terminology or confidentiality, which could lead to miscommunication and potential breaches of privacy.

B. Allow the client's partner to translate: While the partner may understand the language, this approach can create conflicts of interest, and they may not be able to convey the full medical context or sensitive information accurately.

C. Request a female interpreter through the facility: This is the best action. Using a trained, professional interpreter ensures that the communication is accurate and confidential, allowing the nurse to gather necessary admission data effectively while respecting the client's comfort and cultural needs.

D. Have the client's child translate: It is not appropriate to involve a child in medical discussions, as they may not fully understand the context or terminology and could feel overwhelmed by the responsibility.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A) “I should expect the provider to evaluate the client within 4 hours of restraint application.”:The provider must evaluate the client within a shorter timeframe, typically within 1 hour of applying mechanical restraints, to ensure the client’s safety and appropriateness of the intervention.

B) “I should visually monitor the client continuously when in mechanical restraints.”:Continuous visual monitoring is essential to ensure the client’s safety and well-being while in mechanical restraints. This allows for immediate intervention if any complications or distress arise.

C) “I should assess the client’s skin integrity every 8 hours while in mechanical restraints.”:Skin integrity should be assessed more frequently, typically every 2 hours, to prevent skin breakdown and other complications associated with prolonged use of restraints.

D) “I should ask the provider to write a prescription for mechanical restraints as needed.”:Mechanical restraints should not be used on an as-needed basis. They require a specific, time-limited order from a provider, and their use must be justified and documented according to strict guidelines and protocols.

A. Palpable fontanels B. Head circumference exceeds chest circumference C. Natural loss of deciduous teeth D. Nontender, protruding abdomen

Correct Answer is D

Explanation

A) Palpable fontanels:By the age of 2, the anterior fontanel (soft spot on the top of the head) should have closed. Palpable fontanels are not expected in a 2-year-old toddler and could indicate a developmental issue.

B) Head circumference exceeds chest circumference:In a 2-year-old, the head circumference typically equals or is slightly less than the chest circumference. This finding is more common in infants rather than toddlers.

C) Natural loss of deciduous teeth:The natural loss of deciduous (baby) teeth usually begins around the age of 6 years. It is not expected in a 2-year-old toddler.

D) Nontender, protruding abdomen:A nontender, protruding abdomen is a normal finding in toddlers due to their developing musculature and posture. This is a common and expected characteristic in children of this age group.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who has cancer and is experiencing immunosuppression. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who has systemic lupus erythematosus. Which of the following client findings should the nurse expect?

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

A nurse is caring for a client who has cancer and is terminally ill. The client reports feeling depressed. Which of the following statements should the nurse make?

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag, causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of a biohazardous material spill?

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?