A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Request an interpreter of a different sex from the client.

Request a family member or friend to interpret information for the client.

Direct attention toward the interpreter when speaking to the client.

Review the facility policy about the use of an interpreter

Answer and Explanation

The Correct Answer is D

A. Request an interpreter of a different sex from the client. The interpreter's sex should be based on the client’s cultural preferences, not assumed by the nurse. This decision should be made to promote comfort and cultural sensitivity.
B. Request a family member or friend to interpret information for the client. This is not recommended, especially for medical discussions, as it may lead to misinterpretation, breaches of confidentiality, and biased communication.
C. Direct attention toward the interpreter when speaking to the client. The nurse should speak directly to the client, not the interpreter, to maintain a therapeutic relationship and respect for the client.
D. Review the facility policy about the use of an interpreter. This is the most appropriate initial action. Each facility typically has specific guidelines and procedures for accessing qualified medical interpreters, which the nurse should follow to ensure accurate and ethical communication.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Heart rate. The client has a heart rate of 120/min, which is tachycardia and may indicate dehydration, mania-related hyperactivity, or a response to poor nutritional status. This requires immediate follow-up to assess for cardiovascular strain or fluid imbalance.
B. Sleep pattern. While lack of sleep is concerning and a clear symptom of mania, it is a behavioral health issue that typically does not require immediate physiological intervention unless it leads to severe exhaustion or psychosis. It should be addressed, but is not the top priority.
C. Hallucinations. The client is responding to internal stimuli, indicating active psychosis, which poses a safety risk to the client and others. Hallucinations require immediate intervention to stabilize mental health and prevent harm.
D. Skin turgor. Poor skin turgor suggests dehydration, which is a priority physiological concern, especially when paired with tachycardia and failure to recall last food intake. This finding indicates the need for fluid and electrolyte evaluation and possible replacement.
E. Hygiene. The client's unclean appearance reflects self-neglect, a common feature of psychiatric decompensation, and may indicate inability to meet basic needs. This requires prompt attention to prevent complications like infection and assess for functional impairment, though it is secondary to life-threatening physiological or safety concerns.

A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). B. Insert the catheter until resistance is felt. C. Lubricate the catheter with sterile saline. D. Rotate the catheter while suctioning.

Correct Answer is C,B,A,D

Explanation

C. Lubricate the catheter with sterile saline. After donning sterile gloves, the nurse should lubricate the catheter to reduce friction and prevent trauma to the tracheal mucosa during insertion.

B. Insert the catheter until resistance is felt. The catheter should be gently inserted into the tracheostomy until resistance is met, indicating that it has reached the carina. Inserting beyond this point may cause injury.

A. Withdraw the catheter 1 to 2 cm (0.4 to 0.8 in). Pulling back slightly after resistance ensures the catheter is not pressing directly on sensitive structures and is positioned correctly for effective suctioning.

D. Rotate the catheter while suctioning. Suction should be applied while withdrawing the catheter in a rotating motion to evenly clear secretions and minimize damage to the tracheal lining.

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A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits The nurse is assessing the client. Select the 4 findings that require immediate follow-up.

Correct Answer is ["A","C","D","E"]

Explanation

11. A nurse is caring for a client who has a tracheostomy and requires suctioning. Identify the sequence of steps the nurse should follow after applying sterile gloves. (Move the steps into the box, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,B,A,D

Explanation

A nurse is preparing to administer a blood transfusion to a client, which of the following actions should the nurse take?

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A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

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