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A nurse is interviewing a female client who does not speak the same language as the nurse. The client's partner is translating what the nurse is saying to the client. Which of the following actions should the nurse take?
- A. Arrange to complete the data collection with only the client and a translator present.
- B. Ask the client's partner to translate questions and answers for the client.
- C. Record the partner's answers to the questions and complete the assessment.
- D. Ask the partner to allow the client to provide her own answers to the nurse's questions.
Correct Answer: A
Rationale: A professional translator ensures accuracy, maintains confidentiality, and reduces potential biases from family members.
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A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress notes
Correct Answer: A
Rationale: The correct answer is A: Client concerns. The primary source of accurate data about the client should always be the client themselves. Clients are the most reliable sources of information regarding their own health, symptoms, and preferences. By directly asking the client about their concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but may not always be completely accurate. Medical history (C) and progress notes (D) are important sources of information but may not always reflect the client's current status or concerns. It is crucial to prioritize the client's perspective to ensure personalized and effective care.
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
- A. They'll protect your legs and heels from skin breakdown.
- B. They'll help keep you warm immediately after your surgery.
- C. They'll improve your circulation to keep blood from pooling in your legs.
- D. They'll make it easier for you to do leg exercises after your surgery.
Correct Answer: C
Rationale: Correct Answer: C. They'll improve your circulation to keep blood from pooling in your legs.
Rationale:
1. Antiembolism stockings apply gentle pressure to the legs, promoting blood flow.
2. Improved circulation helps prevent blood clots by reducing the risk of venous stasis.
3. By preventing blood pooling, the stockings decrease the chances of deep vein thrombosis.
Incorrect Choices:
A. Skin breakdown prevention is not the primary purpose of antiembolism stockings.
B. Keeping warm is not the main function of these stockings.
D. While leg exercises are important post-surgery, it is not the main reason for using antiembolism stockings.
The family of a client who has died unexpectedly arrives immediately after the death. Which of the following actions should the nurse take?
- A. Ask the family to return after the staff cleans the body.
- B. Perform postmortem care so that the body is prepared for the funeral home.
- C. Have a clergy member present when the family first sees the client.
- D. Allow the family to view the body privately.
Correct Answer: D
Rationale: The correct answer is D: Allow the family to view the body privately. This is important to facilitate the grieving process and provide closure. Allowing the family to view the body privately enables them to say goodbye in their own way and can help them come to terms with the loss. It shows respect for the family's cultural and religious beliefs regarding death and mourning. It also allows for a more personal and intimate experience for the family members.
Choice A is incorrect because asking the family to return after the staff cleans the body may cause unnecessary delays and distress for the family. Choice B is incorrect as performing postmortem care should not take precedence over allowing the family to view the body. Choice C, having a clergy member present, is a supportive gesture but does not address the immediate needs of the family to see the deceased.
A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
- A. Ask the client how strong she feels today.
- B. Ask the client if she has been out of bed today.
- C. Check the client's pedal pulses and feet for edema.
- D. Ask the client to push her legs and feet against the nurse's palms.
Correct Answer: D
Rationale: The correct answer is D. Asking the client to push her legs and feet against the nurse's palms is a direct assessment of the client's muscle strength. This action provides a more objective measure of strength compared to subjective responses (A) or general activity level (B). Checking pedal pulses and feet for edema (C) assesses circulation and fluid status, not strength. Asking the client to perform a physical task (D) allows for a practical evaluation of strength level.
A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.