A nurse is planning preoperative teaching for a client who is scheduled for a cholecystectomy. The client does not speak the same language as the nurse and is accompanied by her adolescent daughter. Which of the following actions should the nurse take?

Ask the client's daughter to interpret the conversation.

Talk loudly while facing the client.

Access a language line to interpret what is being said.

Use a bilingual dictionary to translate.

Answer and Explanation

The Correct Answer is C

Choice A reason: Asking the client's daughter to interpret the conversation is not a correct action, as it may compromise the accuracy and confidentiality of the information. The nurse should not use family members or friends as interpreters, as they may have biases, emotions, or personal agendas that could interfere with the communication.

Choice B reason: Talking loudly while facing the client is not a correct action, as it may be perceived as rude or aggressive by the client. The nurse should not assume that the client can understand them better by increasing the volume or using gestures, as these may have different meanings in different cultures.

Choice C reason: Accessing a language line to interpret what is being said is the correct action, as it ensures that the communication is clear, accurate, and respectful. The nurse should use a qualified interpreter who is familiar with the medical terminology and the cultural context of the client.

Choice D reason: Using a bilingual dictionary to translate is not a correct action, as it may be time-consuming and ineffective. The nurse should not rely on a dictionary or a translation app, as they may not capture the nuances or expressions of the language. The nurse should also avoid using medical jargon or slang that may not be understood by the client.

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Correct Answer is C

Explanation

Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.

Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.

Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.

Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.

A. The emergency department nurse is waiting to give report on a new admission. B. Two staff members have called to say they will be absent. C. Transport assistance is unavailable to take a client to occupational therapy. D. A nurse on the previous shift wrote an incident report about a medication error.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice because this situation is the most urgent and requires immediate action. The charge nurse should prioritize the new admission and assign a staff nurse to receive the report and prepare the room for the client. The charge nurse should also ensure that the client's needs are met and that the admission process is smooth and efficient.

Choice B reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should plan the staffing for the shift and arrange for replacements or reassignments if necessary. The charge nurse should also communicate with the staff members who called in and document their reasons for absence.

Choice C reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should coordinate with the transport department and the occupational therapy department to reschedule the client's appointment or find an alternative way to transport the client. The charge nurse should also inform the client and the staff nurse about the change and apologize for any inconvenience.

Choice D reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should review the incident report and follow up with the nurse who wrote it and the client who was involved. The charge nurse should also implement corrective actions and preventive measures to avoid similar errors in the future.

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A nurse is planning preoperative teaching for a client who is scheduled for a cholecystectomy. The client does not speak the same language as the nurse and is accompanied by her adolescent daughter. Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is A

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