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An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

A.

Turn the overhead lights on while giving instructions.

B.

Stand behind the client to avoid intimidation.

C.

Provide handouts written at a 12th grade reading level.

D.

Use background music to promote relaxation.

Answer and Explanation

The Correct Answer is A

Rationale:

 

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.

 

B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.

 

C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.

 

D. Background music may be distracting rather than helpful during the provision of important instructions.


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Correct Answer is C

Explanation

Rationale:

A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.

B. Peripheral edema is not commonly linked to phenytoin use.

C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.

D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.

Correct Answer is C

Explanation

Rationale:

A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.

B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.

C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.

D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

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