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 B

Explanation

A. Providing condoms in health clinics is a preventive measure but does not directly indicate the effectiveness of the secondary prevention program.

B. Diagnosing at-risk clients early in the disease process indicates successful secondary prevention efforts, as early diagnosis allows for prompt treatment and prevention of further transmission.
C. While increasing HPV vaccine prescriptions is a positive outcome, it does not directly reflect the effectiveness of the program in preventing STIs.
D. Improved client knowledge is important but does not directly measure the program's effectiveness in preventing STIs.

A. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds. C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. D. The client with an obstruction of the large intestine who is experiencing abdominal distention.

Correct Answer is A

Explanation

A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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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

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