Level: Foundational
Difficulty: Easy
Subtopic: Respiratory disorders
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. A…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for pneumonia with increased work of breathing. Assessment data include the client has crackles bilaterally, SpO2 88% on room air, and reports increased shortness of breath. Before teaching, what should the nurse assess first?
Question
A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.