A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?
Sit beside the client.
Speak slowly and loudly to the client.
Dim the lights in the client's room.
Choose a private room for the interview.
The Correct Answer is D
The correct answer is choice D: Choose a private room for the interview.
Choice D rationale:
Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.
Choice A rationale:
Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.
Choice B rationale:
Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.
Choice C rationale:
Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A - Measure the client's gastric residual before each feeding.
Choice A rationale:
The nurse's first action in caring for a client receiving intermittent enteral feedings should be to measure the client's gastric residual before each feeding. Gastric residual volume helps assess the client's tolerance to enteral feedings and can indicate delayed gastric emptying or potential complications like aspiration. If the residual volume is high, the nurse can collaborate with the healthcare team to determine whether to hold the feeding, adjust the feeding rate, or take other appropriate actions to ensure the client's safety and optimal nutritional status.
Choice B rationale:
Changing the enteral feeding bag and tubing every 24 hours is important to maintain the sterility and integrity of the feeding system. However, it is not the first action the nurse should take. The priority is to assess the client's tolerance to the feeding by measuring gastric residuals, which helps prevent complications.
Choice C rationale:
Documenting intake and output is a crucial aspect of nursing care for all clients, including those receiving enteral feedings. However, in the context of intermittent enteral feedings, measuring gastric residuals before each feeding is a more immediate and specific action to ensure the client's safety and well-being.
Choice D rationale:
Flushing the tubing with 30 mL of water after each feeding is important to prevent clogging and maintain the patency of the enteral feeding tube. However, this action is secondary to measuring gastric residuals, which directly assesses the client's tolerance to the feedings and helps prevent complications.
Correct Answer is C
Explanation
The correct answer is Choice C: 3+ pitting edema.
Choice A rationale:
1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.
Choice B rationale:
2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.
Choice C rationale:
3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.
Choice D rationale:
4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.
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