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

After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.

This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.

Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.

Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.

Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.

A. Reinsert the peripheral IV catheter. B. Verify that the restraints can be quickly released. C. Assess capillary refill distal to the restraints. D. Replace the nasogastric tube.

Correct Answer is C

Explanation

When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.

This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.

Choice A, reinserting the peripheral IV catheter, may be necessary but is not the most important action in this situation.

Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.

Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.

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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

After a week of bed rest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?

Correct Answer is A

Explanation

After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube. At checking the restraints, which action is most important for the nurse to take?

Correct Answer is C

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?