An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

Turn the overhead lights on while giving instructions.

Stand behind the client to avoid intimidation.

Provide handouts written at a 12th grade reading level.

Use background music to promote relaxation.

Answer and Explanation

The Correct Answer is A

A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.
B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.
C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.
D. Background music may be distracting rather than helpful during the provision of important instructions.

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Correct Answer is C

Explanation

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

A. Obtain a blood pressure every 15 minutes. B. Monitor the client's complete blood count (CBC) daily. C. Review creatinine and blood urea nitrogen results. D. Measure the client's urinary output daily.

Correct Answer is A

Explanation

A. Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.
B. Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.
C. While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.
D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.

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An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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