A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse take to improve communication?
Provide interpretation services over the telephone.
Use exaggerated lip movements when speaking.
Provide written material at an 8th-grade reading level.
Reduce environmental stimuli.
The Correct Answer is D
Rationale:
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
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Correct Answer is B
Explanation
Rationale:
A. Attaching the NG tube to low intermittent suction is not recommended during gastric lavage, as suctioning can remove the lavage solution before it has a chance to work effectively.
B. Instilling the lavage solution in volumes of 500 mL at a time is correct as it allows for effective cleansing of the stomach and can help to clear out any blood or debris present.
C. Chilled lavage solution should not be used; it is recommended to use room temperature or warmed solution to avoid discomfort and potential complications such as cramping.
D. While 0.9% sodium chloride is isotonic and can be used for irrigation, it is not typically the solution used for gastric lavage; water or a specific lavage solution is more appropriate.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. Polyuria is not typically associated with immobility; instead, immobility can lead to urinary retention.
B. Contractures of the extremities occur due to prolonged immobility, leading to shortening of muscles and tendons.
C. Diarrhea is not a common complication of immobility; constipation is more frequently seen due to decreased mobility.
D. Crackles in the lungs can develop due to stasis of secretions and respiratory complications related to immobility.
E. Pressure ulcers develop from prolonged pressure on the skin due to immobility, especially over bony prominences.