A nurse is preparing to perform preoperative care for a client who does not speak the same language as the nurse. The client has signed the informed consent form, but is refusing preoperative care. Which of the following actions should the nurse take?

Ask the client's son to explain the preoperative interventions.

Inform the provider about the situation with the client.

Reinforce the benefits of the surgery to the client.

Request another client who speaks the same language to act as an interpreter.

Answer and Explanation

The Correct Answer is B

A. Ask the client's son to explain the preoperative interventions. This is not appropriate as it may lead to miscommunication and is not in line with professional standards for interpretation.
B. Inform the provider about the situation with the client. This is correct. The provider should be informed to address the client's refusal of preoperative care appropriately.
C. Reinforce the benefits of the surgery to the client. Reinforcing the benefits does not address the communication barrier and the client's immediate refusal.
D. Request another client who speaks the same language to act as an interpreter. This is inappropriate and breaches confidentiality. Professional interpreters should be used.

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Correct Answer is C

Explanation

A. Increase dietary intake of fats. While fats can help lubricate the intestines, increasing fat intake is not a primary recommendation for managing constipation. Focusing on fiber and fluid intake is more effective.
B. Reduce intake of fluids. Reducing fluid intake can worsen constipation. Adequate hydration is essential to soften stool and promote regular bowel movements.
C. Increase fiber gradually each day. Increasing fiber intake gradually helps prevent constipation. Fiber adds bulk to the stool and helps it move more easily through the digestive tract. A gradual increase prevents gas and bloating that can occur with a sudden high intake of fiber.
D. Reduce dietary intake of probiotics. Probiotics can actually aid in maintaining a healthy digestive system and can help with bowel regularity. Reducing them is not recommended for managing constipation.

A. Schedule a home visit in 3 weeks for weight and growth monitoring. B. Return to the primary health care provider in 3 days for a follow-up appointment. C. Cover the baby with a phototherapy blanket at home when sleeping. D. Return the baby for immunization in 1 month.

Correct Answer is B

Explanation

The correct answer is choiceB. Return to the primary health care provider in 3 days for a follow-up appointment.

Choice A rationale:

Scheduling a home visit in 3 weeks for weight and growth monitoring is not appropriate for a newborn who has recently been treated for jaundice.Close monitoring is essential to ensure that bilirubin levels do not rise again and to assess the baby’s overall health and feeding patterns.

Choice B rationale:

Returning to the primary health care provider in 3 days for a follow-up appointment is the most appropriate action.This allows for early detection of any rebound hyperbilirubinemia and ensures that the baby is feeding well and gaining weight appropriately.

Choice C rationale:

Covering the baby with a phototherapy blanket at home when sleeping is not recommended without medical supervision.Phototherapy should be administered under the guidance of healthcare professionals to monitor the baby’s bilirubin levels and ensure safety.

Choice D rationale:

Returning the baby for immunization in 1 month does not address the immediate need for follow-up care after jaundice treatment.Immunizations are important, but the priority is to monitor the baby’s bilirubin levels and overall health in the short term.

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A nurse is preparing to perform preoperative care for a client who does not speak the same language as the nurse. The client has signed the informed consent form, but is refusing preoperative care. Which of the following actions should the nurse take?

Nursing Test Bank

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