Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Offering the client a bedpan every three hours.

Keeping an emesis basin near the bedside.

Providing oral care every four hours.

Changing the bed linens frequently.

Answer and Explanation

The Correct Answer is D

This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.

Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.

Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.

Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.

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Correct Answer is B

Explanation

Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.

It also allows the nurse to correct any misunderstandings and reinforce key points.

Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.

Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.

Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.

A. A normal reaction to a position change. B. Gait belt applied. C. Orthostatic hypotension noted with dangling. D. Elevated blood sugar probable.

Correct Answer is C

Explanation

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

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Which intervention should the nurse include while caring for a client who has been diaphoretic for the past six hours?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which interventionshouldthe nurse implement when planning to teach older adult clients?

Correct Answer is B

Explanation

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Correct Answer is C

Explanation

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