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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. Monitor the client’s white blood cell count. B. Send wound drainage for culture and sensitivity. C. Institute contact precautions for staff and visitors. D. Explain the purpose of a low bacteria diet. E. Use standard precautions and wear a mask.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.

Choice B rationale

Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.

Choice C rationale

Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.

Choice D rationale

Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.

Choice E rationale

Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.

A. Place the vial with the remainder of the medication into a locked drawer. B. Withdraw the medication into a syringe and label it with the client’s name. C. Ask another nurse to witness the medication being discarded. D. Throw the vial into the trash in the presence of another nurse.

Correct Answer is C

Explanation

Choice A rationale

Placing the vial with the remainder of the medication into a locked drawer is not appropriate because it does not ensure proper documentation and accountability for the remaining medication. Controlled substances require strict documentation and disposal procedures.

Choice B rationale

Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and can lead to errors or contamination. The medication should not be stored for future use in this manner.

Choice C rationale

Asking another nurse to witness the medication being discarded is the correct action. This ensures proper documentation, accountability, and compliance with regulations for the disposal of unused or remaining medications, especially controlled substances.

Choice D rationale

Throwing the vial into the trash in the presence of another nurse is not appropriate. It does not ensure proper documentation, accountability, or safe disposal of the remaining medication. Controlled substances require specific disposal procedures to prevent misuse or diversion.

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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","B","C"]

Explanation

Correct Answer is C

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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A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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?

Correct Answer is C

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?