A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.
The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Have the client demonstrate prescribed wound care.

Provide written instructions in the client's native language.

After each instruction, ask the client if he/she understands.

Have an interpreter repeat the wound care instructions.

Answer and Explanation

The Correct Answer is A

The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.

This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.

Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.

Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.

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Correct Answer is B

Explanation

Hyperkalemia is a condition where there is an elevated level of potassium in the blood.

It can occur in patients with renal disease due to the kidneys’ reduced ability to excrete potassium.

Treatment-related side effects, such as certain medications or chemotherapy, can also contribute to hyperkalemia by altering potassium levels in the body1.

Hyperkalemia can lead to life-threatening cardiac conduction disturbances2.

Therefore, it is important for the nurse to determine the apical pulse rate and rhythm.

Choice A is not correct because comparing muscle strength bilaterally is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice C is not correct because measuring color and amount of urine is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

Choice D is not correct because assessing strength of deep tendon reflexes is not the most important intervention for a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L).

A. Remind the UAP to locate the thermometer before gently inserting the ear. B. Demonstrate the correct technique for pulling the client's auricle up and back. C. Advise the UAP to hold the thermometer securely in place to obtain the measurement. D. Use positive reinforcement to affirm that the procedure being performed correctly.

Correct Answer is D

Explanation

The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.

Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.

Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.

Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.

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A client who had emergency gallbladder surgery yesterday is getting ready to be discharged. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When using a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

Correct Answer is D

Explanation

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A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.
The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?