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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?

Initiate a fall risk protocol for the client.

Record the client’s ability to perform ADLs safely.

Determine the client’s activity tolerance.

Teach the client to shorten the stride to prevent falls.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.

Choice B rationale

Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.

Choice C rationale

Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.

Choice D rationale

Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.

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A. Puts on new gloves when entering a client’s room. B. Uses sterile gloves when handling body fluids. C. Keeps a pair of gloves in uniform pocket. D. Dons sterile gloves when caring for clients with HIV.

Correct Answer is A

Explanation

Choice A rationale

Puts on new gloves when entering a client’s room. This action demonstrates an understanding of standard precautions, which are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. By putting on new gloves when entering a client’s room, the UAP is ensuring that they are not transferring any pathogens from one environment to another, thereby protecting both themselves and the client.

Choice B rationale

Uses sterile gloves when handling body fluids. While it is important to use gloves when handling body fluids, sterile gloves are not necessary unless performing a sterile procedure. Standard gloves are sufficient for most tasks involving body fluids, and the use of sterile gloves in these situations would be an unnecessary use of resources.

Choice C rationale

Keeps a pair of gloves in uniform pocket. This practice is not recommended as it can lead to contamination of the gloves. Gloves should be stored in a clean, dry place and should be taken from the box immediately before use. Keeping gloves in a pocket can expose them to contaminants, which can then be transferred to the client.

Choice D rationale

Dons sterile gloves when caring for clients with HIV. HIV is not transmitted through casual contact, and standard gloves are sufficient for routine care of clients with HIV. Sterile gloves are only necessary for sterile procedures, regardless of the client’s HIV status.

A. Request removal initiated by the Health Information Manager. B. Create an electronic correction after 1400 notes are officially unlocked. C. Enter the occurrence after the 1400 notes and identify as “late entry.”. D. Make an electronic addendum following the 1400 documentation.

Correct Answer is D

Explanation

Choice A rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Choice B rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice C rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Choice D rationale

Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.

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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 A

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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The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

Correct Answer is A

Explanation

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

Correct Answer is D

Explanation

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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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?