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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.

Answer and Explanation

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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A. Gives the client a hug and says, “It is okay to cry when you are sad.”. B. “I am sorry to disturb you at a difficult time. This can wait until later.”. C. While touching the client’s forearm, asks, “Would you like to talk about it?” D. “This is a bad time.I can see you are upset. I can come back later.”. .

Correct Answer is C

Explanation

Choice A rationale

Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.

Choice B rationale

Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

Choice C rationale

While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.

Choice D rationale

Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

A. When the client voided following catheter removal. B. Time of the last dose of IV antibiotic administration. C. Intake and output reports for the previous shift. D. Color of the urine during the catheter removal.

Correct Answer is A

Explanation

Choice A rationale

Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

Choice B rationale

The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

Choice C rationale

Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

Choice D rationale

The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

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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?

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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Take full exam for free 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?

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The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

Correct Answer is A

Explanation

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The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to the client about sexual activity. Which approach is best for the nurse to use?

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

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The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

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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?