An older adult client is brought to the emergency department via ambulance due to a fall. The client does not speak the area's dominant language. Shortly after the client arrives, several family members and a neighbor who called the ambulance arrive, all of whom speak the area's dominant language. When attempting to gather information about what happened, which action by the nurse is appropriate?

Ask the client explain as best as possible what occurred.

Have the neighbor who called the ambulance explain what happened.

Arrange for an interpreter to be present to translate.

Enlist the aid of a family member to Answer the nurse's questions

Answer and Explanation

The Correct Answer is C

A. Asking the client to explain without language support may lead to miscommunication and incomplete information.
B. The neighbor may not have accurate or complete details and is not a reliable source for medical information.
C. Arranging for a professional interpreter ensures accurate and confidential communication, respecting the client’s rights.
D. Family members may unintentionally filter or alter information and might not be appropriate interpreters for medical details.

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Correct Answer is D

Explanation

A. Decreasing the amount of fluids is not appropriate. Adequate fluid intake (2,000–3,000 mL/day) is essential to help fiber work effectively in promoting bowel regularity.
B. Both fruits and vegetables provide important sources of fiber and nutrients; omitting one would reduce the nutritional value of the diet.
C. High-fiber foods are beneficial for digestive health, especially when paired with adequate fluid intake, as in this case.
D. Nothing needs to be changed — the client’s diet is well-balanced with high-fiber foods, fruits, vegetables, and sufficient fluid intake, all of which help maintain healthy bowel function.

A. Ensure charting entries are as concise as possible B. Prioritize subjectivity over objectivity in documentation C. Provide the greatest amount of detail possible in every charting entry D. Complete documentation as soon as possible after client interactions

Correct Answer is D

Explanation

A. While concise documentation is valuable, being overly brief can lead to omission of important information.
B. Documentation should be objective, focusing on facts and observable data rather than subjective impressions.
C. Providing excessive detail can clutter the record and make it harder to identify critical information; relevance and clarity are more important than sheer volume.
D. Completing documentation as soon as possible after client interactions helps ensure accuracy and completeness. Timely documentation reduces the risk of forgetting important details and helps maintain continuity of care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, ten 8-oz glasses (2,500 mL) of fluids. What would the nurse tell the client to change?

Correct Answer is D

Explanation

A new nursing graduate has made an error in documentation that led to an unexpected client outcome. When aiming to avoid future errors, which action should the nurse prioritize?

Correct Answer is D

Explanation

A client returning to the floor after orthopedic surgery is reporting nausea. The nurse is aware that an appropriate intervention is to:

What type of law regulates the practice of nursing?

A client tells a nurse, "I do not think I can have the recommended heart surgery because transfusions are against my religion." What is the best response of the nurse in this situation?

The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk?

When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?

In comparison with licensure, which measures entry-level competence, what does certification validate?

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