A nurse is assisting with the development of an education program for a group of older adults.
Which of the following actions should the nurse take first?

The correct answers are Choices B, C, D, and E.

Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.

Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.

Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.

Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.

Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.

Choice A rationale:

Supplement spoken language with pictures. Rationale: When caring for a client who speaks a different language, supplementing spoken language with pictures or visual aids is a helpful communication strategy. Visual aids can assist in conveying important information, instructions, and concepts effectively, especially when there is a language barrier.

Choice B rationale:

Ask a family member of the client to interpret. Rationale: Relying on a family member to interpret can be problematic, as it may compromise the privacy and confidentiality of the client's healthcare information. Additionally, family members may not always be available or proficient in the required language, making it an unreliable method of communication.

Choice C rationale:

Recognize that the client nodding indicates an understanding of the information. Rationale: Assuming that nodding indicates understanding is not a reliable approach, as nodding can have different cultural interpretations and may not necessarily indicate comprehension. It is important to use clear and simple language, along with visual aids when necessary, to ensure effective communication.

Choice D rationale:

Speak to the client at an increased volume. Rationale: Speaking at an increased volume is not an appropriate approach to communication with a client who speaks a different language. It can be perceived as rude or aggressive and is unlikely to improve understanding. Clear and concise communication, along with visual aids or interpretation services when needed, is a more effective strategy.