The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?

Teach the client to shorten the stride to prevent falls.

Record the client's ability to perform ADLs safely.

Initiate a fall risk protocol for the client.

Determine the client's activity tolerance.

Answer and Explanation

The Correct Answer is B

B. Observing the client's upright posture and smooth, steady gait suggests that she is able to ambulate safely without significant risk of falls.

A. This action may be appropriate if the nurse had observed an unsteady or shuffling gait that could increase the risk of falls. However, in this scenario, the nurse has noted that the client's gait is smooth and steady, indicating good balance and stability.

C. The client's upright posture and smooth, steady gait suggest that she has good mobility and balance, which are not indicative of an increased risk of falls.

D. The client's ability to ambulate with an upright posture and smooth, steady gait indicates that she is tolerating activity well. However, the primary focus at this point should be on documenting her functional abilities and assessing her level of independence in performing ADLs safely.

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Correct Answer is ["10"]

Explanation

To calculate the volume in mL to administer, use the formula:

Volume(mL) = Prescribeddose(mg)/Availableconcentration(mg/mL)

Step 1: Convert the prescribed dose to milligrams
The prescribed dose is 5 grams.

Convert grams to milligrams:

5 grams × 1000 mg/gram = 5000 mg

Step 2: Divide by the concentration
The available concentration is 500 mg/mL.

Calculate the volume:

Volume(mL) = 5000 mg / 500 mg/mL = 10 mL

The nurse should administer 10 mL.

A. Request a family member to remain with the client. B. Ask for the support of one of the client's friends. C. Use drawings that are universal for all cultures. D. Obtain a staff member who is a bilingual interpreter.

Correct Answer is D

Explanation

D. This ensures effective communication between the nurse and the client, allowing the client to express their concerns and enabling the nurse to provide appropriate care and support. Using a bilingual interpreter helps ensure accurate understanding and promotes culturally sensitive care.

A. Involving a family member can provide emotional support and assistance with communication. However, if the family member does not speak the client's language, this intervention may not fully address the client's immediate needs.

B. Asking for the support of a friend can provide emotional support and assistance with communication. However, if the friend does not speak the client's language, their presence is not useful

C. This intervention can help convey information and instructions to the client and may help alleviate fear by providing visual cues. However, it may not fully address the client's need for verbal communication or reassurance.

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The nurse assesses an older adult woman's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that her posture is upright, and her gait is smooth and steady. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes cefuroxime 5 grams every 8 hours IM for a client with pneumonia. The available vial is labeled, "Cefuroxime 500 mg/mL." How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required round to the nearest whole number.)

Correct Answer is ["10"]

Explanation

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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