A client who had emergency gallbladder surgery yesterday is getting ready for discharge. 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?
After each instruction, ask if the client understands.
Have an interpreter repeat the wound care instructions.
Have the client demonstrate prescribed wound care.
Provide written instructions in the client’s native language.
The Correct Answer is C
Choice A rationale
Asking the client if they understand after each instruction may not be effective if the client is not comfortable expressing confusion or misunderstanding. It does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice B rationale
Having an interpreter repeat the wound care instructions may be helpful, but it still does not allow for direct observation of the client’s ability to perform the necessary tasks.
Choice C rationale
Having the client demonstrate prescribed wound care is the best way to evaluate the client’s understanding of self-care at home. This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice D rationale
Providing written instructions in the client’s native language may be helpful, but it does not allow the nurse to directly evaluate the client’s understanding.
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Correct Answer is A
Explanation
Choice A rationale
Puts on new gloves when entering a client’s room. This action demonstrates an understanding of standard precautions, which are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. By putting on new gloves when entering a client’s room, the UAP is ensuring that they are not transferring any pathogens from one environment to another, thereby protecting both themselves and the client.
Choice B rationale
Uses sterile gloves when handling body fluids. While it is important to use gloves when handling body fluids, sterile gloves are not necessary unless performing a sterile procedure. Standard gloves are sufficient for most tasks involving body fluids, and the use of sterile gloves in these situations would be an unnecessary use of resources.
Choice C rationale
Keeps a pair of gloves in uniform pocket. This practice is not recommended as it can lead to contamination of the gloves. Gloves should be stored in a clean, dry place and should be taken from the box immediately before use. Keeping gloves in a pocket can expose them to contaminants, which can then be transferred to the client.
Choice D rationale
Dons sterile gloves when caring for clients with HIV. HIV is not transmitted through casual contact, and standard gloves are sufficient for routine care of clients with HIV. Sterile gloves are only necessary for sterile procedures, regardless of the client’s HIV status.
Correct Answer is D
Explanation
Choice A rationale
Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.
Choice B rationale
Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.
Choice C rationale
Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.
Choice D rationale
Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.