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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Determine the client’s activity tolerance.

Teach the client to shorten the stride to prevent falls.

Initiate a fall risk protocol for the client.

Record the client’s ability to perform ADLs safely.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Determining the client’s activity tolerance is important but should follow the initial assessment of the client’s ability to perform ADLs safely.

Choice B rationale

Teaching the client to shorten the stride to prevent falls is not necessary if the client’s gait is smooth and steady. This intervention is more appropriate for clients with gait instability.

Choice C rationale

Initiating a fall risk protocol for the client is not necessary if the client’s gait is smooth and steady. This protocol is more appropriate for clients with a higher risk of falls.

Choice D rationale

Recording the client’s ability to perform ADLs safely is the next appropriate action. This documentation is essential for the care plan and ensures that the client’s current status is accurately reflected.

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A. Ask the healthcare provider for a mild sedative for bedtime. B. Take an afternoon nap to make up for missed sleep. C. Drink a mixture of warm water, whiskey, and honey at bedtime. D. Establish a regular time for going to bed and getting up. E. Avoid drinking caffeinated beverages late in the day.

Correct Answer is ["D","E"]

Explanation

Choice A rationale

Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency. Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.

Choice B rationale

Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.

Choice C rationale

Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.

Choice D rationale

Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.

Choice E rationale

Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.

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

Correct Answer is D

Explanation

Choice A rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for low molecular weight heparin (LMWH) administration. The air bubble in the prefilled syringe helps ensure the entire dose is delivered and prevents leakage of the medication. Removing the air bubble can lead to an incomplete dose and reduced efficacy of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for LMWH administration. The preferred site for LMWH injections is the abdominal area, specifically at least 2 inches (5.1 cm) from the umbilicus. This site provides better absorption and reduces the risk of complications such as hematoma formation.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH administration. Massaging the site can cause bruising and hematoma formation, which can be painful and may affect the absorption of the medication. It is important to avoid massaging the injection site to minimize these risks.

Choice D rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct instruction for LMWH administration. This site provides optimal absorption and reduces the risk of complications. The abdominal area has a good blood supply, which helps in the effective absorption of the medication. Additionally, injecting at least 2 inches (5.1 cm) from the umbilicus helps avoid the umbilical area, which is more prone to bruising and discomfort.

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

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Correct Answer is ["D","E"]

Explanation

Correct Answer is D

Explanation

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Take full exam for free The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

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An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["D","E"]

Explanation

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Correct Answer is D

Explanation

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?