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 A

Explanation

A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.

A. Tell me about the activities that cause your pain? B. Does your pain occur when walking short distances? C. When did you first notice the pain in your chest? D. How do you feel when the pain becomes noticeable?

Correct Answer is B

Explanation

A. This is an open-ended question, not closed-ended.

B. A closed-ended question like "Does your pain occur when walking short distances?" is specific and allows the nurse to understand the triggers and pattern of the pain, which is important for assessing unstable angina.
C. "When did you first notice the pain in your chest?" is also a relevant question but less specific to understanding the current pattern and triggers of the pain.
D. "How do you feel when the pain becomes noticeable?" is open-ended and less specific in identifying triggers and patterns of the pain.

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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

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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