The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Observe the client's body language.

Ask the client for learning feedback.

Provide client focused information.

Reinforce key points with the client.

Answer and Explanation

The Correct Answer is B

A. Observe the client's body language:

This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.

B. Ask the client for learning feedback:

This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.

C. Provide client-focused information:

This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.

D. Reinforce key points with the client:

This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.

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Correct Answer is C

Explanation

A. Initiate the facility's restraint flow sheet:

- Initiating the facility's restraint flow sheet is an important step for documenting the use of restraints according to institutional policies and regulatory requirements. However, in this scenario where improper use of restraints has been observed, the immediate priority is to address the safety concern and prevent harm to the client.

B. Ensure that the restraints are not too tight:

- Ensuring that the restraints are not too tight is crucial for preventing harm to the client, such as compromised circulation or tissue damage. However, while important, this action is secondary to addressing the observed improper use of restraints, which poses an immediate safety risk to the client.

C. Demonstrate proper securing of the restraints:

Educating the UAP on how to correctly apply restraints is crucial. Incorrectly secured restraints can lead to complications such as injury, infection, or impaired circulation. The nurse should show the UAP how to secure the restraints to amovable part of the bed frame, not to the side rails. This ensures safety and prevents harm if the side rails are released.Proper restraint application helps maintain the client’s safety while minimizing risks.

D. Complete an adverse occurrence/incident report:

- Completing an adverse occurrence/incident report: Reporting incidents is necessary, but it can wait until after ensuring safe restraint application.

A. Irrigate the nasogastric tube with water. B. Perform oropharyngeal suctioning. C. Elevate the head of bed 45 degrees. D. Review the advanced directive document.

Correct Answer is C

Explanation

Correct answer: C

A. Irrigate the nasogastric tube with water:

This option is not the best immediate action when a client is choking after vomiting. While irrigating the nasogastric tube with water may help clear the tube itself, it does not directly address the choking episode or potential airway obstruction. The priority in this situation is to ensure the client's airway is clear and maintain their safety.

B. Perform oropharyngeal suctioning:

While suctioning might be used later to clear the airway of secretions, it's not the first-line intervention when someone is actively choking. Suctioning can stimulate the gag reflex and worsen vomiting..

C. Elevate the head of bed 45 degrees:

The primary concern is preventing aspiration (inhaling vomit) which can lead to serious complications. Elevating the head of the bedhelps keep the head and neck in a position that promotes drainage of fluids and reduces the risk of aspiration.

D. Review the advance directive document:

Reviewing the advance directive document is important for understanding the client's wishes regarding their healthcare decisions, but it is not the appropriate action in the immediate management of a choking episode. Ensuring the client's safety and addressing the choking episode take precedence over reviewing documentation.

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The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Nursing Test Bank

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