A nurse is completing the admission process for an older adult client new to the unit. After gathering the assessment data and reviewing the health history, which of the following best promotes client safety?

Conduct a client care conference

Provide information about advance directives

Orient the client to his room

Develop a plan of care

Answer and Explanation

The Correct Answer is C

Choice A reason: Conducting a client care conference is important for multidisciplinary care planning, but it may not immediately address the client's safety needs upon admission. Safety measures should be implemented promptly to prevent potential accidents or confusion.

Choice B reason: Providing information about advance directives is crucial for ensuring that the client's wishes are respected during their care. However, this does not directly address immediate safety concerns that may arise from being in a new environment.

Choice C reason: Orienting the client to his room is essential to promote client safety. This includes familiarizing the client with the layout of the room, location of the bathroom, call bell, and any other essential features. It helps prevent falls and accidents by reducing confusion and ensuring the client knows how to access help if needed.

Choice D reason: Developing a plan of care is critical for long-term management of the client's health needs. However, immediate safety concerns should be addressed first to ensure a safe environment for the client from the outset.

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Correct Answer is B

Explanation

Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

A. A client admitted for a cholecystectomy 2 days ago with decreased bowel sounds. B. A client admitted for diabetes mellitus with a blood glucose of 140 mg/dL. C. A client admitted for a left femur fracture with new-onset confusion. D. A client admitted for dehydration with a BP of 105/77 mm Hg.

Correct Answer is C

Explanation

Choice A reason: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client.

Choice B reason: A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients.

Choice C reason: A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications. Therefore, this client should be prioritized first.

Choice D reason: A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.

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A nurse is completing the admission process for an older adult client new to the unit. After gathering the assessment data and reviewing the health history, which of the following best promotes client safety?

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