Nokea
A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?
- A. Have the client demonstrate prescribed wound care.
- B. Provide written instructions in the client's native language.
- C. After each instruction, ask the client if he/she understands.
- D. Have an interpreter repeat the wound care instructions.
Correct Answer: A
Rationale: The best way to evaluate the client's understanding of self-care at home is to have the client demonstrate prescribed wound care. This allows the nurse to directly observe the client's ability to perform the necessary tasks and provide feedback and clarification as needed.
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Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?
- A. To ambulate without discomfort.
- B. To take analgesics as prescribed.
- C. To show evidence of incision healing.
- D. To avoid pain-causing activity.
Correct Answer: A
Rationale: The goal of the care plan should be to help the client overcome his activity intolerance related to pain. This can be achieved by helping him to ambulate without discomfort.
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
- A. I'm sorry but your son's medical information is none of your business.
- B. The healthcare provider will share this information with you.
- C. I can only give medical information to your son because he is an adult.
- D. I will get these results back from the lab as soon as possible.
Correct Answer: C
Rationale: The best response for the nurse to provide is 'I can only give medical information to your son because he is an adult.' Since the client is 19 years old and considered an adult, the nurse must respect the client's right to privacy and confidentiality.
The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.Which action should the nurse implement?
- A. Remind the UAP to locate the thermometer before gently inserting the ear.
- B. Demonstrate the correct technique for pulling the client's auricle up and back.
- C. Advise the UAP to hold the thermometer securely in place to obtain the measurement.
- D. Use positive reinforcement to affirm that the procedure being performed correctly.
Correct Answer: D
Rationale: The UAP is correctly pulling the client's auricle up and back and preparing to insert the thermometer.
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?
- A. Places food on the unaffected side of the mouth.
- B. Raises the head of the bed to 80 degrees.
- C. Positions the head with the chin tilted slightly downward.
- D. Allows 30 minutes of rest before feeding.
Correct Answer: B
Rationale: Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.