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 B
Explanation
The correct answer is B.
Choice A reason: Using a stiff toothbrush to clean the client’s teeth is not recommended. A stiff toothbrush can cause damage to the gums and teeth, especially in clients who may have sensitive oral tissues due to medications or medical treatments.
Choice B reason: Turning the client on his side before starting oral care is the most appropriate action. This is to prevent aspiration, especially in immobile clients who may have difficulty swallowing or clearing their throat.
Choice C reason: Using the thumb and index finger to keep the client’s mouth open is not recommended. This could be uncomfortable or even harmful for the client. Instead, a padded tongue blade could be used if necessary, but only with extreme caution and the client’s comfort in mind.
Choice D reason: Applying petroleum jelly to the client’s lips after oral care is also a good practice. This helps to prevent dryness and cracking of the lips, which can be a common problem for hospitalized patients, especially those who are dehydrated or receiving oxygen therapy. However, when compared to choice B, it is not as critical in terms of immediate safety concerns.
Correct Answer is A
Explanation
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