An older adult client who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?

Ensure that someone will stay with the client for 24 hours.

Have the client vocalize the instructions provided.

Speak clearly and face the client for lip reading.

Provide written instructions for eye drop administration.

None

Answer and Explanation

The Correct Answer is B

A.   Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B.   The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C.   Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providing written instructions for eye drop administration is useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.

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Correct Answer is D

Explanation

A. Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B. Repositioning the patch is not necessary as it is properly placed for its intended effect.
C. While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D. Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

A. IV administration of benztropine. B. PO administration of divalproex. C. PO administration of lorazepam. D. IV administration of isotonic crystalloid fluid.

Correct Answer is A

Explanation

A. Benztropine is an anticholinergic medication that is effective in rapidly treating acute dystonic reactions, including laryngeal spasms, which can be life-threatening. It works by counteracting the imbalance of neurotransmitters caused by certain medications.
B. Divalproex is used for mood stabilization and seizure control but is not effective in treating acute dystonic reactions.
C. Lorazepam, while useful for anxiety and agitation, is not the first-line treatment for dystonic reactions and does not address the underlying neurotransmitter imbalance.
D. Isotonic crystalloid fluids are important for hydration but do not treat the cause of the dystonic reaction.

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An older adult client who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Correct Answer is D

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is A

Explanation

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