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.

Teach the client to shorten the stride to prevent falls.

Determine the client's activity tolerance.

Record the client's ability to perform ADLS safely.

Answer and Explanation

The Correct Answer is C

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

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Correct Answer is D

Explanation

A. Clamping the urinary catheter prior to the collection:

This step involves temporarily stopping the flow of urine through the catheter. Whether gloves are needed for this step depends on the specific protocol and the potential risk of exposure to bodily fluids. If there's a possibility of urine leakage or splashing during the clamping process, gloves may be necessary to protect against contact with the urine.

B. Recording the output on the flowsheet in the client's room:

This step involves documenting the urine output on a flowsheet or chart. It typically does not require direct contact with bodily fluids, as the nurse is handling paperwork rather than the urine itself. Therefore, gloves are usually not necessary for this task.

C. Transporting the urine specimen to the laboratory:

Once the urine specimen has been collected and properly sealed in a biohazard bag, the nurse transports it to the laboratory for analysis. As long as the specimen is securely packaged, there is no need for gloves during transportation unless there is a risk of spillage or leakage. However, if there is a possibility of contact with bodily fluids due to leakage, gloves should be worn to protect against exposure.

D. Using the syringe to remove the specimen from the catheter:

This step involves using a sterile syringe to withdraw the urine from the catheter for collection. Since it involves direct contact with bodily fluids (i.e., urine), gloves are necessary to protect against potential exposure to pathogens. Wearing gloves during this step helps maintain proper infection control practices and minimizes the risk of contamination.

A. Administer PRN oral pain medication. B. Review the pain medications prescribed. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is C

Explanation

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is D

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The healthcare provider prescribes a 24 hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?