A nurse is planning teaching for a client who will be discharged with a central venous access device. Which of the following actions should the nurse plan to take first?
Make a priority list of information the client should learn.
Determine the client's learning needs.
Select a visual method to reinforce verbal teaching for the client.
Obtain written information to give the client.
The Correct Answer is B
Rationale
A. Make a priority list of information the client should learn: Creating a priority list is important for organizing teaching content, but it should follow an assessment of the client’s specific learning needs. Prioritization without understanding the client’s knowledge gaps may result in irrelevant or ineffective teaching.
B. Determine the client's learning needs: Assessing the client’s learning needs is the first step in planning effective education. This allows the nurse to identify what the client already knows, what they need to learn, and any barriers to learning, ensuring that subsequent teaching is individualized and relevant.
C. Select a visual method to reinforce verbal teaching for the client: Choosing teaching methods is important for reinforcing learning, but it should be done after determining the client’s needs and preferred learning style. Methods are most effective when tailored to the client’s assessed needs.
D. Obtain written information to give the client: Providing written materials supports retention and understanding, but it should follow an assessment of the client’s needs to ensure the content is appropriate and comprehensible. Giving generic materials without assessment may not address the client’s specific concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices
- Nasogastric tube: The client is experiencing nausea, vomiting, abdominal distension, firm abdomen, hypoactive/absent bowel sounds, and has not passed flatus since surgery, indicating possible postoperative ileus or gastric distension. Inserting a nasogastric tube can help decompress the stomach, relieve nausea, and prevent further complications such as aspiration.
- Opioid analgesic: The client reports increased incisional pain (5/10) and discomfort associated with abdominal distension. Administering an opioid analgesic as prescribed helps manage pain, allowing for comfort, mobility, and participation in postoperative care.
Rationale for Incorrect Choices
- Chest tube: Chest tubes are used to drain air, blood, or fluid from the pleural space and are not indicated for abdominal distension or postoperative ileus. Additionally, the clients lung sounds are normal with adequate saturation on supplementary oxygen.
- Urinary catheter: The client’s urinary output is adequate (480 mL in 8 hr),averaging 60 mL/hr so a urinary catheter is not necessary at this time and does not address abdominal distension or nausea.
- Antibiotics: There is no evidence of infection at this time. Prophylactic or therapeutic antibiotics are not indicated solely for postoperative pain or nausea without signs of infection.
- Antihypertensive: The client’s blood pressure (104/68 mm Hg) is slightly lower than earlier but does not warrant antihypertensive therapy. Administering such medication could worsen hypotension and perfusion.
Correct Answer is B
Explanation
Rationale
A. The provider obtains verbal consent for the procedure without witnessing the client's signature: While verbal consent may be appropriate for some low-risk procedures, most invasive or high-risk procedures require written consent. Obtaining consent without documentation does not meet legal or ethical standards for informed consent and may place both the client and provider at risk.
B. The provider performing the procedure is responsible for obtaining informed consent: The provider who will perform the procedure must ensure the client understands the risks, benefits, alternatives, and potential outcomes. This responsibility ensures the client receives accurate, procedure-specific information from the person most qualified to answer questions and address concerns.
C. The nurse's role is to provide the client with initial information about the procedure prior to obtaining informed consent: The nurse’s role is to reinforce teaching, clarify information, and ensure the client comprehends the procedure. Nurses can answer questions and verify understanding but do not obtain legal consent for invasive procedures.
D. Clients are unable to change their mind once a consent form is signed: Clients have the right to withdraw consent at any time, even after signing the consent form. Respecting autonomy means that the client can refuse or discontinue a procedure without penalty, and this right must be communicated as part of the informed consent process.
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