When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Speak loudly and face the client.

Provide a very well lit meeting space.

Use everyday language when explaining issues.

Underline key words on the written information.

Answer and Explanation

The Correct Answer is C

A. Speak loudly and face the client:

While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

B. Provide a very well-lit meeting space:

Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

C. Use everyday language when explaining issues:

This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

D. Underline key words on the written information:

This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.

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Correct Answer is D

Explanation

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

A. Document the absence of the radial pulse. B. Release the manometer valve immediately. C. Inflate blood pressure cuff to 120 mm Hg. D. Record a palpable systolic pressure of 90 mm Hg.

Correct Answer is C

Explanation

A. Document the absence of the radial pulse:

While it's important to document findings accurately, it's also crucial to ensure that blood pressure measurements are obtained correctly. If the radial pulse becomes unpalpable before reaching the expected systolic pressure, further action is needed to obtain an accurate measurement.

B. Release the manometer valve immediately:

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement. This action is not appropriate at this stage.

C. Inflate blood pressure cuff to 120 mm Hg:

When the radial pulse becomes unpalpable during cuff inflation, it indicates that the cuff pressure is above the systolic pressure. To accurately determine the systolic pressure, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

D. Record a palpable systolic pressure of 90 mm Hg:

If the radial pulse is no longer palpable at 90 mm Hg, this suggests that the true systolic pressure is higher than 90 mm Hg. Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure.

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When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Correct Answer is D

Explanation

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is C

Explanation

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