A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Provide an artificial voice box.

Avoid using facial gestures.

Speak to the client in a louder voice.

Ask the client close-ended questions.

Answer and Explanation

The Correct Answer is D

A. Provide an artificial voice box - This is not typically used for clients with aphasia as it does not address the communication barriers they face.
B. Avoid using facial gestures - Facial gestures can be a helpful non-verbal communication tool, especially for clients with aphasia, so avoiding them is not beneficial.
C. Speak to the client in a louder voice - Aphasia affects language processing, not hearing, so increasing volume does not aid in understanding.
D. Ask the client close-ended questions - This allows the client to respond with 'yes' or 'no', or other simple answers, which can be easier for someone with aphasia.

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Correct Answer is B

Explanation

A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.

A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D. Perform the wound irrigation with a 10mL syringe with an angiocatheter.

Correct Answer is A

Explanation

A. Administer an analgesic 30 min before starting the procedure: Correct. Before performing wound irrigation, it is essential to provide pain relief to the client. Administering an analgesic 30 minutes before the procedure will help manage pain during wound irrigation.
B. Hold the syringe 5 cm (2 in) above the upper end of the wound: This action does not contribute to proper wound irrigation. The nurse should direct the irrigation solution to the wound site to cleanse it effectively.
C. Place the irrigation solution in a basin of cool water: Using cool water is not the best practice for wound irrigation. The irrigation solution should be at room temperature or a temperature specified by the healthcare provider.
D. Perform the wound irrigation with a 10mL syringe with an angiocatheter: Wound irrigation typically requires a larger volume of fluid to adequately cleanse the wound. A 10mL syringe may not be sufficient, and using an angiocatheter is not appropriate for wound irrigation. A larger syringe or irrigation solution bag with an appropriate wound irrigation tool is usually used.

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A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Correct Answer is B

Explanation

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

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A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

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