A nurse is caring for a client who is postoperative.
Vital Signs.
0800: Nurses' Notes.
BP 118/72 mm Hg. Heart rate 82/min.
Respiratory rate 16/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
1000: BP 128/82 mm Hg. Heart rate 94/min.
Respiratory rate 18/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
Vital Signs.
Nurses' Notes.
0745: Client awake and eating breakfast while watching the news on television.
Client has hearing loss, does not wear a hearing aid, and TV volume is loud.
Rates pain as a 2 on a 0 to 10 pain scale.
Incisional dressing dry and intact.
1000: Nurses' Notes.
Client ambulated in the hallway with a physical therapist.
Client grimacing, appears upset, and is guarding incisional site.
Reports pain as 5 on a 0 to 10 pain scale.
Opioid analgesic administered.
1045: Client resting with eyes closed and listening to music with earphones.
Reports feeling "very sleepy" after pain medication.
Now rates pain as a 3 on a 0 to 10 pain scale.
1300: Ate 75% of lunch.
Several visitors at the bedside.
Which of the following factors could present a barrier to the nurse effectively communicating with the client? Select all that apply.
Client's hearing deficit.
Volume of the client's television.
Numerous visitors in the client's room.
Increase in pain after ambulation.
Adverse effects of opioid analgesic.
Using earphones while listening to music.
Correct Answer : A,B,C,E,F
The correct answers are a. Client's hearing deficit, b. Volume of the client's television, c. Numerous visitors in the client's room, e. Adverse effects of opioid analgesic, and f. Using earphones while listening to music.
Choice A rationale: A client with hearing loss who does not wear a hearing aid may experience difficulty understanding spoken communication, especially in noisy environments, leading to potential miscommunication or misunderstanding.
Choice B rationale: Loud television volume can make it difficult for both the nurse and the client to hear each other, causing interference in their communication and potentially leading to errors in information exchange.
Choice C rationale: The presence of numerous visitors in the room can cause distractions, background noise, and overall interference with the nurse-client communication process, potentially affecting the quality and accuracy of the information exchanged.
Choice E rationale: Opioid analgesics can cause adverse effects such as drowsiness, confusion, or cognitive impairment, hindering effective communication between the nurse and the client, as the client's ability to comprehend, retain, and convey information may be impaired.
Choice F rationale: The use of earphones while listening to music can impair the client's ability to hear the nurse, creating a barrier to effective communication. This could potentially lead to missed or misunderstood information and, consequently, affect the quality of care.
Choice D rationale (Incorrect choice): While an increase in pain after ambulation could affect the client's mood, cooperation, and ability to engage in effective communication, it does not directly create a barrier to the nurse's ability to communicate with the client. Pain management is an essential aspect of postoperative care, and effective communication can actually facilitate pain assessment, management, and overall client well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: A
Choice A reason: Providing the nurse administering medications with an identifying vest can help reduce medication errors by making it easier for other staff and patients to identify the nurse responsible for medication administration. This can minimize interruptions and distractions, which are common causes of medication errors. It also serves as a visual reminder to the nurse of their critical role in medication safety.
Choice B reason: Removing medications from automatic dispensing systems before they are reviewed by pharmacists is not a recommended practice. Pharmacists play a crucial role in reviewing prescriptions for accuracy and potential drug interactions before dispensing. Therefore, medications should remain in the dispensing system until they have been properly reviewed and approved by a pharmacist.
Choice C reason: Waiting to document medications given to clients until the end of a shift is not advisable. Accurate and timely documentation is essential in healthcare, particularly when it comes to medication administration. Documentation should occur as soon as the medication is given to ensure that all healthcare providers have up-to-date information and to prevent errors such as omissions or duplications.
Choice D reason: Preparing medications for multiple clients at the same time increases the risk of errors, such as mix-ups between patients or incorrect dosing. It is best practice to prepare and administer medications for one client at a time, following the ‘five rights’ of medication administration: the right patient, the right drug, the right dose, the right route, and the right time.
Correct Answer is A
Explanation
Choice A rationale:
Health promotion is the correct concept demonstrated by the nurse. Health promotion refers to activities and strategies that aim to enhance an individual's overall health and well-being. Educating the client with heart disease about the importance of eating a heart-healthy diet is a proactive step towards improving their health.
Choice B rationale:
Holistic health is a broader approach that considers the whole person, including physical, mental, and social aspects. While it is an important concept, the nurse, in this scenario, is primarily focused on educating the client about a specific aspect of their health, which is heart disease management.
Choice C rationale:
Health education is a component of health promotion, but it specifically refers to the process of providing individuals with knowledge and skills to make informed decisions about their health. In this case, the nurse is providing education as a means of promoting the client's health.
Choice D rationale:
Primary prevention involves measures to prevent the development of a disease or condition before it occurs. While promoting a heart-healthy diet is a form of prevention, it does not specifically align with the concept of primary prevention, which typically involves actions taken to avoid the initial occurrence of a health problem.
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