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 A
Explanation
Choice A rationale
Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.
Choice B rationale
Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.
Choice C rationale
Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.
Choice D rationale
Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.
Correct Answer is D
Explanation
Choice A rationale
Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.
Choice B rationale
Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.
Choice C rationale
Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.