A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Rephrase statements the client does not hear.
Determine if the client uses hearing aids.
Speak using his usual tone of voice and directly in front of the client.
Use hand gestures to communicate.
The Correct Answer is B
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.
Choice B rationale
Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.
Choice C rationale
Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.
Choice D rationale
Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.
Correct Answer is D
Explanation
Choice A rationale
Stating that the client had an allergic reaction to the ordered meperidine is not objective and does not provide specific details about the client’s condition.
Choice B rationale
Notifying the primary health care provider because the client developed a rash after receiving an opioid analgesic is important, but it does not include all the necessary details about the client’s condition.
Choice C rationale
Documenting that the client’s skin was warm and flushed, and a rash was noted on the chest and back is important, but it does not include the timing of the reaction or the client’s temperature.
Choice D rationale
Documenting that thirty minutes after receiving meperidine, the temperature was 101°F (38.3°C), the client’s skin was warm and flushed, and a rash was noted on the chest and back provides a complete and objective account of the client’s condition and the timing of the reaction.