The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss.

The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father.

Which intervention(s) should the nurse implement? (Select all that apply.).

Include the family in the discharge teaching.

Encourage the client to attend reading classes.

Face the client when speaking.

Speak loudly when teaching.

Provide the daughter with written instructions.

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale:

Including the family in the discharge teaching is essential, especially when dealing with a client who has communication barriers such as hearing loss and illiteracy. Involving the daughter in the teaching process ensures that she is aware of the client's care needs and can provide support at home.

Choice B rationale:

Encouraging the client to attend reading classes is not a practical intervention for an older adult with hearing loss. Reading classes may not address the immediate communication needs of the client, and the client's primary caregiver, in this case, is the daughter who will provide daily care and support.

Choice C rationale:

Facing the client when speaking is a crucial intervention when dealing with someone who has hearing loss. By facing the client, the nurse ensures that the client can see their lips and facial expressions, which can aid in lip-reading and understanding the communication better.

Choice D rationale:

Speaking loudly when teaching is not always the best approach for clients with hearing loss. While it may seem intuitive to speak loudly, it can distort speech and make it more challenging for the client to understand. Clear and slow speech, along with visual cues, is often more effective.

Choice E rationale:

Providing the daughter with written instructions is essential, especially when the client has limited reading skills. Written instructions can serve as a reference guide for the daughter, helping her provide care and support to her father accurately.

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Correct Answer is B

Explanation

Choice A rationale:

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice C rationale:

Serum albumin levels can be relevant in assessing nutritional status and the body's ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage. Low serum albumin levels may be seen in clients with malnutrition but do not provide immediate information about the wound.

Choice D rationale:

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

A. Apply gloves and empty the drainage bag B. Remove the looped tubing from the bed C. Measure the urinary output in the bag D. Attach the drainage bag to the bed frame

Correct Answer is D

Explanation

The correct answer is choice d. Attach the drainage bag to the bed frame.

Choice A rationale:

Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.

Choice B rationale:

Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.

Choice C rationale:

Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.

Choice D rationale:

Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.

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Naxlex Comprehensive Predictor Exams

While caring for a client with a full-thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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