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.
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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Correct Answer is B
Explanation
Choice A rationale
Whether the popsicles contain pulp or fruit is not relevant to the clear liquid diet, which focuses on the clarity and digestibility of the liquids.
Choice B rationale
The color and flavor of gelatin used are important because certain colors, especially red or purple, can interfere with medical tests and are often avoided in clear liquid diets.
Choice C rationale
If the popsicles are completely frozen is not relevant to the dietary restrictions. The focus should be on the ingredients and their suitability for a clear liquid diet.
Choice D rationale
The number of popsicles available does not impact their suitability for the child’s diet. The nurse should focus on the content and appropriateness of the popsicles.
Correct Answer is D
Explanation
Choice A rationale
Adhering to the medication regimen is important, but it does not specifically address the client’s ability to self-administer insulin, which is crucial for managing hyperglycemia post- discharge.
Choice B rationale
Auscultating breath sounds every 4 hours is important for monitoring respiratory status but does not address the client’s need to manage their diabetes through self-injection of insulin.
Choice C rationale
Demonstrating the ability to change the ostomy bag is important for postoperative care but does not address the specific need for managing hyperglycemia through insulin self- administration.
Choice D rationale
Ensuring the client can self-administer insulin injections before discharge is crucial for managing their hyperglycemia and maintaining their health post-discharge.