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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. Determine client’s subjective measure of pain using a numerical pain scale. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Provide comfort measures such as topical warm application and tactile massage. E. Encourage increased fluid intake and measure urinary output every 8 hours.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.

Choice B rationale

Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.

Choice C rationale

Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.

Choice D rationale

Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.

Choice E rationale

Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.

A. Remind the UAP to lubricate the thermometer before gently inserting it in the ear. B. Advise the UAP to hold the thermometer securely in place for a full three minutes. C. Demonstrate the correct technique for pulling the client’s auricle down and back. D. Use positive reinforcement to affirm that the procedure is being performed correctly.

Correct Answer is D

Explanation

Choice A rationale

Lubricating the thermometer before inserting it into the ear is not a standard practice for using a tympanic thermometer. Tympanic thermometers are designed to be used without lubrication, and using lubrication could interfere with the accuracy of the reading.

Choice B rationale

Holding the thermometer in place for a full three minutes is unnecessary for tympanic thermometers. These thermometers provide quick readings, usually within a few seconds, and holding it for longer does not improve accuracy.

Choice C rationale

Pulling the client’s auricle down and back is the correct technique for infants and young children. For adults, the correct technique is to pull the auricle up and back to straighten the ear canal for an accurate reading.

Choice D rationale

Using positive reinforcement to affirm that the procedure is being performed correctly is the appropriate action. The UAP is using the correct technique by pulling the client’s auricle up and back, which is the proper method for adults.

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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 ["A","B","D"]

Explanation

Correct Answer is D

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 is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client 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?

Correct Answer is D

Explanation

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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?