The nurse is preparing to measure vital signs and provide AM care ...

[CBme]

The nurse is preparing to measure vital signs and provide AM care for a client from another culture. The priority action of a culturally competent nurse before beginning care would be which of the following?
 
  1. Explain the procedure and seek permission to touch the client.
  2. Perform the task quickly to minimize embarrassment.
  3. Tell the client what is being done and why during the procedure.
  4. Explain the need for the procedures.

Question 2

An unconscious 38-year-old client is brought to the Emergency Department after a motorcycle accident. The nurse is assessing the client, and notes several lacerations that contain dirt, pebbles, and glass.
 
  The nurse anticipates that care for this client will include cleaning and dressing the wounds and which of the following? 1. Applying cold packs to the wounds
  2. Administering a tetanus booster
  3. Completing the nursing history
  4. Assessment of treated wounds

[Tabitha_2016]

Answer to Question 1

1
Rationale 1: Answer option 1 is correct because the culturally competent nurse recognizes the importance of explaining what will be done and seeking permission before beginning, allowing the client the dignity of participating. The remaining options do not offer the client a choice or seek permission for touching the client before beginning.

Answer to Question 2

2
Rationale: The client is unconscious, and has road debris in his wounds. The nurse would anticipate giving a tetanus booster to this client, because he would be unable to report when he had his last booster shot. Cold packs would not be applied to the wounds until they are treated. Since the client is unconscious, the nurse will not anticipate completing the nursing history. Assessment of treated wounds will occur on the unit after admission rather than in the Emergency Department.