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 D

Explanation

D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.

A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.

B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.

C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.

A. Reassure the client that someone will help with positioning on the bedpan. B. Encourage the client to use a bedside commode rather than the bedpan. C. Explain to the client that the head of the bed can be elevated when using the bedpan. D. Offer to position the bedpan on the chair before the client transfers to the chair.

Correct Answer is B

Explanation

B. A bedside commode allows the client to sit comfortably and maintain independence while toileting. Using a commode chair near the bed reduces the need for bedpan use and promotes mobility.

A. Reassurance is important, but simply reassuring the client without addressing their specific concerns or providing practical solutions may not fully address the issue.

C. Elevating the head of the bed can help with using the bed pan but does not include the other plan of care as a bedside commode would.

D. While positioning the bedpan on the chair may provide an alternative option for the client, it may not be the most practical solution, especially if the client is able to use the bedpan while in bed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the client to self-administer a dose of low-molecular-weight heparin (LMWH) SUBQ: Which instruction should the nurse include?

Correct Answer is D

Explanation

Following surgery, a client expresses concern to the nurse about being able to use the bedpan. After noting that the client's prescribed postoperative activity includes getting up to a chair three times a day, how should the nurse intervene?

Correct Answer is B

Explanation

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