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?

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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. The client will demonstrate the ability to change the ostomy bag in two days. B. The client attempts to self-administer insulin but is unable to perform the injection. C. The client’s breath sounds will be auscultated by the nurse every 4 hours. D. The client will adhere to the medication regimen after discharge.

Correct Answer is D

Explanation

Choice A rationale

This outcome statement focuses on the client’s ability to perform a specific task related to ostomy care. While it’s important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

Choice B rationale

This outcome statement indicates the client’s attempt to self-administer insulin but inability to perform the injection. While it’s important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

Choice C rationale

This outcome statement focuses on monitoring the client’s respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client’s primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

Choice D rationale

This outcome statement directly addresses the client’s need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client’s health needs and goals following the surgical procedure and the development of hyperglycemia.

A. Record a palpable systolic pressure of 90 mm Hg. B. Release the manometer valve immediately. C. Document the absence of the radial pulse. D. Inflate the blood pressure cuff to 120 mm Hg.

Correct Answer is D

Explanation

Choice A rationale

Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.

Choice B rationale

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.

Choice C rationale

Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.

Choice D rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

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?

Free Nursing Test Bank

Correct Answer is D

Explanation

Correct Answer is D

Explanation

Quick Links

Resources

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?

Free Nursing Test Bank

Correct Answer is D

Explanation

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results. Which response is best for the nurse to provide?

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

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?

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

The primary nurse went on break at 1845.The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?

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.

Quick Links

Resources

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?