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.

Answer and Explanation

The Correct Answer is D

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.   Having the client vocalize the instructions ensures that the client understands and can recall the information provided, which is crucial for compliance with self-care. However, it does not provide a point of reference while at home.
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 is crucial because written instructions can serve as a reference for the client to review as needed, ensuring they understand and follow the postoperative care procedures, which is essential for preventing complications and promoting healing.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.
B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.
C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.
D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.
E. New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

A. Propose that the nurse use the antecubital site for IV access. B. Send an unlicensed assistive personnel to gather equipment. C. Direct the nurse to remove the needle before the procedure. D. Suggest starting a secondary infusion at the IV tubing

Correct Answer is C

Explanation

A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.

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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

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

Correct Answer is ["A","B","C","E"]

Explanation

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take?

Correct Answer is C

Explanation

Exhibits Nursing actions: Indicated/contraindicated/non-urgent

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