Nokea
The nurse is reinforcing discharge teaching for a client who has a low health literacy level. Which of the following actions should the nurse take? Select all that apply.
- A. Provide as much detail as possible.
- B. Utilize the teach-back method.
- C. Repeat important information.
- D. Use visual aids.
- E. Speak loudly.
Correct Answer: B,C,D
Rationale: Teach-back confirms understanding, repeating key points reinforces learning, and visual aids simplify concepts. Excessive detail overwhelms low-literacy clients, and loud speech is unnecessary unless hearing-impaired.
You may also like to solve these questions
The nurse is talking with a client with alcohol use disorder who has a new prescription for disulfiram. Which of the following information should the nurse include?
- A. Most clients who take this medication do not need to attend therapy or support groups.
- B. Avoid drinking alcohol for 3 days after discontinuing this medication.
- C. Check for alcohol in household items you use regularly, such as mouthwash.
- D. You can expect to experience decreased cravings for alcohol.
Correct Answer: C
Rationale: Disulfiram causes severe adverse reactions when alcohol is consumed, even in small amounts found in products like mouthwash. Clients must avoid all alcohol-containing products to prevent a disulfiram-alcohol reaction, which can include nausea, vomiting, and flushing.
When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?
- A. Tachycardia, blurred vision, hypotension, anorexia
- B. Orthostatic hypotension, vertigo, reactions to tyramine-rich foods
- C. Diarrhea, dry mouth, weight loss, reduced libido
- D. Photosensitivity, seizures, edema, hyperglycemia
Correct Answer: C
Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.
Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.
- A. I will clarify with my health care provider before taking enteric-coated medications.
- B. I will irrigate the colostomy to promote regular bowel movements.
- C. I will limit eating foods such as broccoli and cauliflower to reduce odor.
- D. I will restrict my fluid intake to 2,000 milliliters of fluid a day.
- E. I will wait for the pouch to become completely full before emptying the contents.
Correct Answer: A,C
Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
The nurse is reinforcing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds.
- B. Keep the head of the bed elevated at night.
- C. Wear socks and gloves when going outside.
- D. Know the signs and symptoms of thrombosis.
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising the risk of thrombosis. Teaching the client to recognize signs and symptoms of thrombosis, such as swelling or pain in extremities, is critical. Avoiding large crowds relates to infection risk, not thrombosis. Elevating the head of the bed is unrelated, and wearing socks and gloves is more relevant for conditions like Raynaud's.