An older woman 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?

Have the client vocalize the instructions provided.

Provide written instructions for eye drop administration.

Speak clearly and face the client for lip reading.

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

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Having the client vocalize the instructions provided ensures that they have understood the information correctly. This method allows the nurse to confirm comprehension and clarify any misunderstandings.

Choice B rationale:

Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions. It is a good supplementary measure but should not be the sole method of communication.

Choice C rationale:

Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments. However, it does not guarantee that the client has understood the instructions.

Choice D rationale:

Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.

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

Explanation

A) Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B) Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C) Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D) Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E) Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F) Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.

A. Check the client's level of consciousness. B. Determine the depth of the slashes. C. Estimate the amount of blood loss. D. Find the object used to cause the injuries.

Correct Answer is A

Explanation

Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.

Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.

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An older woman 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

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

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

Explanation

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

Correct Answer is A

Explanation

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