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?
Turn the overhead lights on while giving instructions.
Stand behind the client to avoid intimidation.
Provide handouts written at a 12th grade reading level.
Use background music to promote relaxation.
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 B
Explanation
Rationale:
A. Administering albuterol may help if the shortness of breath is due to bronchospasm, but the priority in heart failure is to assess fluid status and respiratory function.
B. Listening to lung fields is crucial to assess for signs of pulmonary edema, which is a common complication in heart failure. This assessment helps determine the effectiveness of the furosemide and whether further intervention is needed.
C. Measuring urine output is important but secondary to assessing respiratory status.
D. Reviewing serum potassium is important but not as urgent as assessing the client's respiratory status.
Correct Answer is D
Explanation
Rationale:
A. Withdrawing and reinserting the NGT should only be done if the tube is misplaced or dislodged.
B. Sending the fluid to the lab is unnecessary unless there is a specific concern, such as infection.
C. Connecting the NGT to wall suction should only be done after confirming proper placement.
D. Determining the pH value of the aspirated fluid helps verify that the NGT is correctly positioned in the stomach. Gastric fluid typically has a pH of 1 to 5, confirming proper placement.