A nurse is planning teaching for a client who will be discharged with a central venous access device. Which of the following actions should the nurse plan to take first?
Make a priority list of information the client should learn.
Determine the client's learning needs.
Select a visual method to reinforce verbal teaching for the client.
Obtain written information to give the client.
The Correct Answer is B
Rationale
A. Make a priority list of information the client should learn: Creating a priority list is important for organizing teaching content, but it should follow an assessment of the client’s specific learning needs. Prioritization without understanding the client’s knowledge gaps may result in irrelevant or ineffective teaching.
B. Determine the client's learning needs: Assessing the client’s learning needs is the first step in planning effective education. This allows the nurse to identify what the client already knows, what they need to learn, and any barriers to learning, ensuring that subsequent teaching is individualized and relevant.
C. Select a visual method to reinforce verbal teaching for the client: Choosing teaching methods is important for reinforcing learning, but it should be done after determining the client’s needs and preferred learning style. Methods are most effective when tailored to the client’s assessed needs.
D. Obtain written information to give the client: Providing written materials supports retention and understanding, but it should follow an assessment of the client’s needs to ensure the content is appropriate and comprehensible. Giving generic materials without assessment may not address the client’s specific concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Stroking the lower abdomen: Stroking the lower abdomen is not an evidence-based technique to stimulate bladder emptying. It may provide minimal sensory feedback but does not effectively trigger the micturition reflex in clients experiencing postoperative urinary retention.
B. Leaning backward when sitting and attempting to urinate: Leaning backward can actually impede proper bladder emptying by kinking the urethra. Proper positioning for urination involves sitting upright or leaning slightly forward to facilitate relaxation of the pelvic floor and urethral alignment.
C. Performing Kegel exercises prior to urination: Kegel exercises strengthen pelvic floor muscles and are useful for improving long-term urinary continence, but performing them immediately prior to attempting urination can tighten the muscles and hinder urine flow. This technique does not promote immediate bladder emptying.
D. Pouring warm water over the perineum: Pouring warm water over the perineum can stimulate sensory nerves and activate the micturition reflex, promoting bladder contraction and facilitating urination. This is a noninvasive, effective technique commonly used for clients experiencing postoperative urinary retention.
Correct Answer is D
Explanation
Rationale
A. Add yogurt to enteral feedings: While yogurt contains probiotics, adding it directly to enteral feedings can alter the formula’s consistency and increase the risk of tube clogging. It is not a standard intervention for diarrhea associated with enteral nutrition.
B. Change to an enteral formula that has added fiber: Formulas with added fiber are beneficial for managing chronic diarrhea or constipation, but switching formulas should be guided by the provider or dietitian rather than implemented independently.
C. Add water during tube flushes: Adding water helps maintain hydration and prevent tube clogging but does not directly address the underlying cause of diarrhea. While important for overall care, it is not the primary intervention to manage diarrhea.
D. Slow down the instillation flow rate: Rapid administration of enteral feedings can overwhelm the gastrointestinal system and contribute to diarrhea. Slowing the flow rate allows for better tolerance, reduces osmotic load, and often resolves diarrhea associated with high-volume or fast feedings.
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