An older adult client who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care?
Ensure that someone will stay with the client for 24 hours.
Have the client vocalize the instructions provided.
Speak clearly and face the client for lip reading.
Provide written instructions for eye drop administration.
None
None
The Correct Answer is B
A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providing written instructions for eye drop administration is useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Raising the head of the bed can help improve lung expansion and reduce aspiration risk, which is beneficial for a client with pneumonia. However, while this intervention supports respiratory function, it does not directly address the systemic perfusion and organ failure risks associated with septic shock. Therefore, it is not the highest priority intervention in a sepsis protocol.
B. Blood glucose monitoring is important in sepsis because stress-induced hyperglycemia is common and uncontrolled glucose can worsen outcomes. However, this intervention is supportive rather than critical in the early management of septic shock and does not take priority over interventions that directly evaluate perfusion and organ function.
C. Strict intake and output monitoring is essential in septic shock because it provides immediate information about renal perfusion and fluid balance. Septic shock causes widespread vasodilation and capillary leak, leading to decreased organ perfusion and acute kidney injury. Urine output is a key indicator of organ function and response to fluid resuscitation, making this intervention a core component of sepsis management.
D. Assessing extremity warmth helps evaluate peripheral perfusion and can indicate early versus late septic shock. While this is a useful assessment, it is less critical than objective measures such as urine output that directly reflect organ perfusion and guide treatment decisions.
Correct Answer is D
Explanation
A. Lorazepam is not indicated for preventing Wernicke's syndrome.
B. Famotidine is a histamine-2 blocker used to reduce stomach acid secretion and treat gastritis symptoms but does not prevent Wernicke's syndrome.
C. Atenolol is a beta-blocker used to treat hypertension and angina, not to prevent Wernicke's syndrome.
D. Thiamine supplementation is essential in individuals with chronic alcohol abuse to prevent Wernicke's syndrome, which is caused by thiamine deficiency.
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