An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

Over-enunciate word syllables.

Exaggerate nonverbal expressions.

Decrease speaking speed.

Raise voice volume to a shout.

Answer and Explanation

The Correct Answer is C

A. Over-enunciating word syllables can be perceived as patronizing and may not improve understanding for clients with hearing difficulties.
B. Exaggerating nonverbal expressions can help convey meaning, but it does not address the immediate need for clear verbal communication.
C. Decreasing speaking speed allows the client more time to process what is being said, which is particularly important for older adults who may need additional time to understand spoken words.
D. Raising voice volume to a shout may not be necessary and could distort the clarity of speech, making it harder for the client to understand.

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Correct Answer is B

Explanation

A. While the nurse can perform oral care, it is essential for the UAP to assist where appropriate, and oral care should not be solely left for the nurse.
B. A soft-bristled toothbrush is the best option for the client with painful mouth ulcers, as it is gentle and reduces the risk of further irritation.
C. Offering mouthwash may not be appropriate, especially if it contains alcohol, as it could further irritate the ulcers; additionally, thorough cleansing is typically more effective with careful brushing rather than rinsing alone.
D. Wearing sterile gloves is unnecessary for oral care; standard precautions, including clean gloves, should be used, but sterile gloves are not required for this type of care.

A. Determine the client's last dose of corticosteroids. B. Determine neurological baseline prior to the fall. C. Administer a PRN IV antiemetic as prescribed. D. Complete head-to-toe neurological assessment.

Correct Answer is D

Explanation

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Exhibits The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Exhibits Which prescriptions would the nurse question? Select all that apply.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates that the client understands the instructions for using this medication?