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.

Answer and Explanation

The Correct Answer is D

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 D

Explanation

A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.

A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's tubing every 48 hr.

Correct Answer is A

Explanation

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.

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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?

Nursing Test Bank

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