The nurse is teaching a client about a newly prescribed medication.
To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Provide client-focused information.

Reinforce key points with the client.

Observe the client’s body language.

Ask the client for learning feedback.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Providing client-focused information is essential, but it does not confirm that the client has understood the critical information. It is a part of the teaching process but not a confirmation strategy.

Choice B rationale

Reinforcing key points with the client helps emphasize important information but does not ensure that the client has learned and understood it. It is a supportive strategy rather than a confirmation method.

Choice C rationale

Observing the client’s body language can provide clues about their understanding and comfort level but is not a definitive way to confirm learning. It should be used in conjunction with other strategies.

Choice D rationale

Asking the client for learning feedback is the most effective strategy for confirming that the client has understood the critical information. It encourages active participation and allows for real-time clarification.

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Correct Answer is D

Explanation

Choice A rationale

Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.

Choice B rationale

Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.

Choice C rationale

Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.

Choice D rationale

Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.

A. Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus. B. Rotate injections between the abdomen and gluteal areas. C. Massage the injection site to increase absorption. D. Expel the air in the prefilled syringe prior to injection.

Correct Answer is A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

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The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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The nurse is teaching a client about a newly prescribed medication.
To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?