An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

Raise voice volume to a shout.

Exaggerate nonverbal expressions.

Decrease speaking speed.

Over-enunciate word syllables.

Answer and Explanation

The Correct Answer is D

A. Raising the voice volume to a shout can be startling for the client and may come across as aggressive or disrespectful.
B. Exaggerating nonverbal expressions might not effectively address the client's difficulty in hearing. While nonverbal communication is essential, especially for older adults with hearing impairments, exaggerating gestures may not necessarily improve communication clarity.
C. Speaking more slowly can help the client better understand what is being said without the nurse needing to shout, which might cause discomfort or further confusion.
D. Over-enunciating or exaggerating expressions can appear patronizing, and shouting can be distressing.

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Correct Answer is C

Explanation

C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.

A. The client's primary issue appears to be respiratory distress rather than fever.

B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.

D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.

A. Encourage deep breathing and coughing exercises. B. Obtain vital signs every 2 hours during hospitalization. C. Provide an eye shield to be worn while sleeping. D. Teach a family member to administer eye drops.

Correct Answer is C

Explanation

C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.

A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.

B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority

D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.

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An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

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