A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?
Determining the client's mobility
Explaining the roles of the RN, licensed practical nurse, and assistive personnel
Introducing health care team members to the client
Understanding the client's routine for his own care at home
The Correct Answer is D
A. Determining the client's mobility
Important for safety and fall prevention, but not the first priority during care planning.
B. Explaining the roles of the RN, licensed practical nurse, and assistive personnel
This is part of orientation and education but does not help in personalized care planning.
C. Introducing health care team members to the client
While courteous and important for building rapport, it’s not the first step in individualized care planning.
D. Understanding the client's routine for his own care at home
This helps in personalizing the care plan to maintain the client’s independence and preferences, especially for older adults in long-term care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Left the patient with the lap robe tucked underneath.
A lap robe is used for warmth and comfort; tucking it under does not pose a risk.
B. Left the brakes of the wheelchair unlocked.
Wheelchair brakes must be locked during transfers to prevent the chair from moving and causing a fall.
C. Placed the patient's feet centered on the footrests.
Feet should be properly placed to avoid dragging or injury.
D. Placed slippers on the patient.
This is appropriate as long as the slippers are non-skid, providing safe footing during transfer.
Correct Answer is B
Explanation
A. Reassess the area in 8 hours
Delaying action may result in wound dehiscence or further tissue damage.
B. Stop the machine and notify the primary care provider
Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.
C. Increase the angle of the flexion of the joint to change the pressure on the heel
Increasing the angle may worsen the wound separation and increase pressure on the incision.
D. Pad the portion of the machine that the heel rests on
Padding may prevent pressure injury but does not address the wound issue or tightness from movement.
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