A nurse is caring for an older client on a medical-surgical unit.Which of the following interventions should be included in the plan of care?
Monitor the client’s hydration status.
Encourage the client to engage in physical activities.
Administer medications as prescribed.
Educate the client on dietary needs.
The Correct Answer is A
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging the client to drink cool water or sports drinks is appropriate for mild dehydration or heat exhaustion but not sufficient for severe heat-related illness like heat stroke, where immediate medical intervention is needed.
Choice B rationale
Administering acetaminophen 650 mg orally can help reduce fever, but it does not address the underlying issue of hyperthermia and will not provide immediate cooling needed in this emergency.
Choice C rationale
Starting an intravenous line and infusing 0.9% saline solution helps rapidly replace fluids lost through sweating and can stabilize the client's condition by rehydrating and cooling them effectively.
Choice D rationale
Encouraging rest and reassessing in 15 minutes would delay necessary medical treatment in a situation where immediate action is critical due to the severity of the client's symptoms.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Administering IV opioids can help manage the intense pain associated with frostbite, improving patient comfort during rewarming and recovery.
Choice B rationale
After rewarming, the extremity should be elevated, not lowered, to reduce edema by encouraging fluid return to the central circulation.
Choice C rationale
Immersing hands and feet in warm water is a crucial step in the rewarming process, which helps restore blood flow and prevent further tissue damage.
Choice D rationale
Elevating affected limbs after rewarming helps reduce edema and prevents further swelling and complications.
Choice E rationale
Tetanus prophylaxis is recommended in frostbite cases as frostbite injuries can break the skin, increasing the risk of tetanus infection. Hence, avoiding tetanus prophylaxis is incorrect.
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