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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?

A.

After each instruction, ask if the client understands.

B.

Have an interpreter repeat the wound care instructions.

C.

Have the client demonstrate prescribed wound care.

D.

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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Correct Answer is A

Explanation

Choice A rationale

Using everyday language when explaining issues is the most important action. This ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

Choice B rationale

Providing a very well-lit meeting space is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

Choice C rationale

Speaking loudly and facing the client is important for ensuring the client can hear and understand the information. However, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

Choice D rationale

Underlining key words on the written information can be a helpful strategy for emphasizing important points, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading.

Correct Answer is B

Explanation

Choice A rationale

Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.

Choice B rationale

Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.

Choice C rationale

Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.

Choice D rationale

Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.

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