A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?
State the options loudly in a high-pitched voice.
Ask the client's partner to choose their meal.
Expect extended time for verbal responses.
Ask the client to point to items on a picture menu.
The Correct Answer is D
Rationale:
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.
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Correct Answer is A
Explanation
Rationale:
A. Assessing the client's IV site every 8 hours is appropriate to prevent complications such as infection or infiltration, especially in an immunocompromised client.
B. Checking the client's WBC count every 48 hours is insufficient; it should be monitored more frequently due to the client's immunocompromised state.
C. Monitoring the client's mouth every 8 hours is necessary, but not as critical as regular IV site assessments.
D. Changing the client's tubing every 48 hours may not be necessary unless indicated by the facility's protocol or the client's condition; continuous IV tubing is typically changed every 72 to 96 hours unless there are signs of complications.
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.