Level: Foundational
Difficulty: Easy
Subtopic: Cardiac conduction and perfusion
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to cardiac conduction an…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to cardiac conduction and perfusion. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. 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.