A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

A. Observe the client's body language:

This strategy involves paying attention to the client's non-verbal cues, such as facial expressions, posture, and gestures, to gauge their level of understanding and engagement. While body language can provide valuable insights into the client's receptiveness to the information being presented, it may not always accurately reflect their comprehension or ability to recall important details. Therefore, while observing body language is beneficial, it should be supplemented with other strategies for a more comprehensive assessment of learning.

B. Ask the client for learning feedback:

This strategy involves actively soliciting feedback from the client to assess their understanding of the material presented. By asking questions such as, "Can you repeat back to me how you will take this medication?" or "Do you have any concerns or questions about the information I've provided?" the nurse can directly gauge the client's comprehension and address any areas of confusion or misunderstanding. Asking for learning feedback encourages active participation from the client and provides an opportunity for real-time clarification, making it a highly effective strategy for confirming learning.

C. Provide client-focused information:

This strategy involves tailoring the educational content to meet the specific needs, preferences, and learning styles of the client. By presenting information in a manner that resonates with the client's individual characteristics and circumstances, such as using plain language, visual aids, or culturally sensitive materials, the nurse can enhance the client's understanding and retention of the material. Providing client-focused information fosters a more personalized and relevant learning experience, which can contribute to better outcomes and adherence to treatment recommendations.

D. Reinforce key points with the client:

This strategy involves reviewing and emphasizing important information multiple times throughout the teaching session to reinforce learning and retention. Repetition helps solidify key concepts in the client's memory and increases the likelihood of successful recall and application of the information. By revisiting key points, summarizing key concepts, and providing opportunities for practice or self-assessment, the nurse can help reinforce the client's understanding and confidence in managing their medication regimen. Reinforcing key points with the client ensures that critical information is consistently emphasized and internalized, which is essential for promoting safe and effective medication use.

A. Switch to a non-rebreather mask:

A non-rebreather mask delivers a higher concentration of oxygen (typically 10-15 L/min) compared to a nasal cannula. However, switching to a non-rebreather mask is a more drastic step that might not be necessary immediately. Other, simpler interventions should be considered first.

B. Verify placement of pulse oximeter:

Before making any changes, it's crucial to verify the accuracy of the oxygen saturation reading. The pulse oximeter might be misplaced or malfunctioning, leading to an inaccurate reading. This is an appropriate first action to ensure the reading is correct before deciding on further interventions.

C. Remove nasal cannula:

Removing the nasal cannula would decrease the client’s oxygenation further, worsening the situation. This is not an appropriate action when oxygen saturation is already low.

D. Increase the oxygen to 3 L/minute:

Increasing the oxygen flow rate is a reasonable intervention to improve oxygen saturation. However, this should typically be done after verifying the accuracy of the oxygen saturation reading. If the reading is correct, this is a valid next step to improve the client’s oxygenation.