A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.
The nurse knows that 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?

Have the client demonstrate prescribed wound care.

Provide written instructions in the client's native language.

After each instruction, ask the client if he/she understands.

Have an interpreter repeat the wound care instructions.

Answer and Explanation

The Correct Answer is A

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

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Correct Answer is A

Explanation

Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome.

In this case, the nurse should document the assessment that is not within normal limits, which is “Basilar lung sounds that are diminished in the left lung.”

Choice B is not the answer because contraction of the left pupil when light shines in the right eye is a normal finding known as consensual pupillary response.

Choice C is not the answer because capillary refill of 2 seconds in the lower right foot is a normal finding.

Choice D is not the answer because active bowel sounds in the lower right quadrant are a normal finding.

A. Ask the client to describe the pain. B. Provide a numeric pain scale. C. Identify effective pain relief measures. D. Observe body language and movement.

Correct Answer is B

Explanation

The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.

According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.

Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.

Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.

Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.

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A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is A

Explanation

An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain. To assess the intensity of the client's pain, which approach should the nurse use?

Correct Answer is B

Explanation

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A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.
The nurse knows that 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?