The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady.
Which action should the nurse take next?

Initiate a fall risk protocol for the client.

Record the client’s ability to perform ADLs safely.

Determine the client’s activity tolerance.

Teach the client to shorten the stride to prevent falls.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.

Choice B rationale

Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.

Choice C rationale

Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.

Choice D rationale

Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.

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Correct Answer is C

Explanation

Choice A rationale

Placing the vial with the remainder of the medication into a locked drawer is not appropriate because it does not ensure proper documentation and accountability for the remaining medication. Controlled substances require strict documentation and disposal procedures.

Choice B rationale

Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and can lead to errors or contamination. The medication should not be stored for future use in this manner.

Choice C rationale

Asking another nurse to witness the medication being discarded is the correct action. This ensures proper documentation, accountability, and compliance with regulations for the disposal of unused or remaining medications, especially controlled substances.

Choice D rationale

Throwing the vial into the trash in the presence of another nurse is not appropriate. It does not ensure proper documentation, accountability, or safe disposal of the remaining medication.

Controlled substances require specific disposal procedures to prevent misuse or diversion.

A. Risk for infection. B. Self-care deficit. C. Impaired physical mobility. D. Risk for impaired skin integrity.

Correct Answer is D

Explanation

Choice A rationale

Risk for infection is a concern for clients with neuropathy, as they may have reduced sensation and be unaware of injuries that can become infected. However, the primary concern in promoting foot care is preventing the occurrence of wounds or skin breakdown in the first place.

Choice B rationale

Self-care deficit is relevant for clients with neuropathy who may have difficulty performing foot care independently. However, the priority is to prevent skin breakdown and wounds, which can lead to more severe complications.

Choice C rationale

Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and ensuring proper foot care to avoid complications.

Choice D rationale

Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.

Preventing skin breakdown and maintaining skin integrity is crucial in this scenario.

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

Correct Answer is C

Explanation

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

Correct Answer is D

Explanation

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The nurse assesses an older adult client’s ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client’s posture is upright, and the gait is smooth and steady.
Which action should the nurse take next?