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

Answer and Explanation

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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Correct Answer is B

Explanation

A. A hard, painless nodule may indicate a deformity but is not an emergency.

B. Erythema and edema at the base of the left great toe could indicate an infection, such as cellulitis, which requires immediate intervention to prevent complications.
C. Decreased response to pain discrimination suggests neuropathy, which is concerning but not immediately life-threatening.
D. Painful corns and calluses are chronic issues that need management but are not urgent.

A. Increase fluid intake to 3,000 mL/daily. B. Provide frequent rest periods. C. Administer O2 at 5 L/minute per nasal cannula. D. Maintain the client in a semi-Fowler's position.

Correct Answer is A

Explanation

A. Increasing fluid intake helps thin pulmonary secretions, making them easier to expectorate and is most directly related to clearing the airway.
B. Providing frequent rest periods is important but does not directly clear the airway.

C. Administering O2 addresses hypoxia but does not clear secretions.

D. Semi-Fowler's position helps with breathing but does not specifically address thick secretions.

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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?

Nursing Test Bank

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