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.

Obtain written information to give the client.

Select a visual method to reinforce verbal teaching for the client.

Answer and Explanation

The Correct Answer is B

A. Make a priority list of information the client should learn: While making a priority list of information is important, it should come after assessing the client's learning needs. This ensures that the most relevant and important information is prioritized.

B. Determine the client's learning needs: The first step in planning teaching is to assess the client’s learning needs. This allows the nurse to tailor the teaching plan to the client’s level of understanding, cultural preferences, and specific concerns related to the central venous access device.

C. Obtain written information to give the client: Written information is helpful but should not be the first step. It is more effective when tailored to the client’s learning needs, which should be assessed first to ensure relevance.

D. Select a visual method to reinforce verbal teaching for the client: Visual methods can be helpful for reinforcing verbal teaching, but this step should follow the assessment of the client’s learning needs. Teaching strategy should align with the client’s preferred learning style.

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Correct Answer is C

Explanation

A. Add water during tube flushes: Adding water during tube flushes is important for maintaining tube patency and hydration but does not directly address diarrhea. It is not a primary solution for managing diarrhea caused by enteral feedings.

B. Change to an enteral formula that has added fiber: While fiber can help regulate bowel movements, changing to a formula with added fiber is not the first intervention for diarrhea. A slow-down of the feeding rate may be more effective to allow the digestive system more time to process the formula.

C. Slow down the instillation flow rate: Slowing down the flow rate of the enteral feeding can reduce the likelihood of diarrhea. A rapid infusion rate can overwhelm the intestines and lead to diarrhea, so adjusting the flow rate is an appropriate first step.

D. Add yogurt to enteral feedings: While yogurt contains probiotics that might help with gut health, adding it to the feeding may not be advisable unless specifically indicated. The primary step for managing diarrhea is adjusting the flow rate of the feeding.

A. Stroking the lower abdomen B. Pouring warm water over the perineum C. Performing Kegel exercises prior to urination D. Leaning backward when sitting and attempting to urinate

Correct Answer is B

Explanation

A. Stroking the lower abdomen: While this may sometimes stimulate the bladder, it is not the most effective technique for promoting urination. Techniques such as using warm water are more commonly recommended for stimulating urination.

B. Pouring warm water over the perineum: Pouring warm water over the perineum can help relax the pelvic muscles and stimulate the urge to urinate. This method is often used to assist with the initiation of urination, especially after catheter removal.

C. Performing Kegel exercises prior to urination: Kegel exercises strengthen the pelvic floor muscles and can improve urinary control over time, but they are not effective for immediately stimulating urination, especially in the postoperative period.

D. Leaning backward when sitting and attempting to urinate: Leaning backward may make it more difficult to urinate as it puts pressure on the bladder. The best position for urination is sitting upright with the feet flat on the floor, which allows relaxation of the pelvic muscles.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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