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.
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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Correct Answer is C
Explanation
Choice A rationale
Offering therapeutic support and comfort to a grieving family does not typically require the structured communication format of SBAR. This interaction is more about providing emotional support and empathy rather than conveying specific clinical information.
Choice B rationale
Obtaining clarification from a client’s healthcare power-of-attorney may involve detailed discussions, but it is not the primary context for SBAR. SBAR is designed for concise, structured communication about clinical situations.
Choice C rationale
Reporting a change in a client’s condition to the healthcare provider is the ideal scenario for using SBAR. This format ensures that critical information is communicated clearly and efficiently, which is essential for patient safety and effective clinical decision-making.
Choice D rationale
Completing discharge teaching to a client and family members involves providing comprehensive education and instructions, which is not the primary purpose of SBAR. SBAR is more suited for brief, focused communication about specific clinical issues.
Correct Answer is D
Explanation
Choice A rationale
Beginning the collection the next day is not necessary. The 24-hour urine collection can be started immediately with the next void. Delaying the collection may cause unnecessary inconvenience and prolong the client’s hospital stay.
Choice B rationale
Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure that the collection starts with an empty bladder. Including the initial sample would result in inaccurate measurement of creatinine clearance.
Choice C rationale
Observing the sample for sediment is not relevant to the collection process for creatinine clearance. The focus should be on ensuring accurate timing and collection of all urine produced within the 24-hour period.
Choice D rationale
Starting the collection with the next void is the correct action. The 24-hour urine collection should begin with an empty bladder, and the first urine of the day is discarded. The time is noted, and all subsequent urine is collected for the next 24 hours. This ensures accurate measurement of creatinine clearance.