A nurse educated a client about how to perform wound care. What action should the nurse take next?

Ask the client to describe the wound care steps to evaluate teaching effectiveness.

Set goals that the client will be able to perform wound care independently.

Assess the wound for complications and document the findings in the client's chart.

Document in the electronic health record the client's risk for deficient knowledge.

Answer and Explanation

The Correct Answer is A

A. Ask the client to describe the wound care steps to evaluate teaching effectiveness: Evaluating the client’s understanding is the next step after education. Asking the client to verbalize or demonstrate the steps ensures they have correctly learned the procedure and allows the nurse to clarify any misconceptions.

B. Set goals that the client will be able to perform wound care independently: Goal-setting occurs during the planning phase of the nursing process. While important, it should be established before or during teaching rather than immediately after instruction.

C. Assess the wound for complications and document the findings in the client's chart: Wound assessment is an ongoing clinical responsibility but does not directly evaluate the effectiveness of the client’s learning or teaching provided.

D. Document in the electronic health record the client's risk for deficient knowledge: Documentation of teaching and learning outcomes is essential, but it should follow the evaluation of the client’s understanding to reflect accurate progress and identify remaining educational needs.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Safe:
• A nurse cleans their stethoscope before auscultating the client's lungs
• A nurse raises the bed to waist level when completing a physical assessment
• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall
• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze

Unsafe:
• A nurse administers medication to a client despite the name on the ID band not matching what the client said
• A client's family lowers all of the side rails on the bed of a client who is on fall precautions

Rationale

• A nurse cleans their stethoscope before auscultating the client's lungs: Cleaning the stethoscope reduces the risk of transmitting pathogens between clients, promoting infection control. This is a standard safe practice in clinical care.

• A nurse raises the bed to waist level when completing a physical assessment: Raising the bed to waist level allows the nurse to maintain proper body mechanics and reduce risk of musculoskeletal injury. This is consistent with safe patient handling protocols.

• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall: Assisting a client who is stable and using a mobility aid is safe, as long as the UAP follows proper techniques and ensures the client’s stability during ambulation.

• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze: Using the elbow or upper arm to cover a sneeze prevents the spread of respiratory droplets, reducing infection risk. This is recommended over using hands, which can contaminate surfaces.

• A nurse administers medication to a client despite the name on the ID band not matching what the client said: Administering medication without verifying the correct identity violates the “right patient” safety protocol. This can result in medication errors and harm, making it unsafe.

• A client's family lowers all of the side rails on the bed of a client who is on fall precautions: Lowering side rails for a patient at fall risk increases the likelihood of injury from falls. Side rails should be maintained according to the patient’s safety plan, making this action unsafe.

A. Allergy assessment B. Skin temperature and color C. Reason for seeking care D. Posture and speech

Correct Answer is D

Explanation

A. Allergy assessment: This is part of the client’s medical history and does not fall under the general survey, which focuses on observable, overall physical and behavioral characteristics.

B. Skin temperature and color: While skin assessment is important, detailed measurements of temperature and specific color changes are usually part of the physical examination, not the initial general survey.

C. Reason for seeking care: This is subjective information provided by the client and is part of the health history, rather than the general survey, which emphasizes observable characteristics.

D. Posture and speech: Posture, gait, speech, and overall appearance are key elements of the general survey. These observations provide an immediate impression of the client’s general health, functional status, and level of comfort.

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A nurse educated a client about how to perform wound care. What action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager assesses safety on the medical-surgical floor. For each scenario, click to specify whether each scenario is safe or unsafe.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

A nurse is documenting findings following the examination of a client. Which should the nurse include as part of the general survey?

Correct Answer is D

Explanation

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