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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nonmaleficence: By completing training before administering chemotherapy, the nurse ensures they do not cause harm to clients. Nonmaleficence emphasizes the ethical responsibility to prevent injury or harm through safe and competent care.
B. Veracity: Veracity involves truthfulness and honesty in interactions with clients, such as providing accurate information about treatments. While important, completing training primarily addresses safety, not truth-telling.
C. Autonomy: Autonomy refers to respecting a client’s right to make informed decisions about their care. Completing training does not directly relate to client decision-making.
D. Fidelity: Fidelity involves keeping commitments and being faithful to professional responsibilities. While training supports professional competence, the key ethical principle demonstrated here is preventing harm, aligning with nonmaleficence.
Correct Answer is B
Explanation
A. Appreciate other cultures: Appreciation of other cultures is important, but without first understanding one’s own biases and values, the nurse may unintentionally impose personal beliefs or misunderstand the client’s perspective. Cultural appreciation alone is insufficient for competent care.
B. Assess one's own cultural values, beliefs, and biases: Self-assessment is the first step in providing culturally competent care. By recognizing personal beliefs, assumptions, and potential biases, the nurse can approach clients with greater awareness, respect, and sensitivity, minimizing the risk of culturally inappropriate care.
C. Examine information about other cultures: Learning about other cultures is valuable for understanding traditions, beliefs, and practices. However, this step is most effective after self-reflection, as knowledge alone does not ensure culturally competent interactions.
D. Learn to speak different languages: Language skills can enhance communication and trust with clients, but they are not the initial step. Effective cultural competence begins with self-awareness, which provides a foundation for meaningful and respectful interactions.
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