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

Teach the client to shorten the stride to prevent falls.

Record the client's ability to perform ADLs safely.

Initiate a fall risk protocol for the client.

Determine the client's activity tolerance.

Answer and Explanation

The Correct Answer is B

B. Observing the client's upright posture and smooth, steady gait suggests that she is able to ambulate safely without significant risk of falls.

A. This action may be appropriate if the nurse had observed an unsteady or shuffling gait that could increase the risk of falls. However, in this scenario, the nurse has noted that the client's gait is smooth and steady, indicating good balance and stability.

C. The client's upright posture and smooth, steady gait suggest that she has good mobility and balance, which are not indicative of an increased risk of falls.

D. The client's ability to ambulate with an upright posture and smooth, steady gait indicates that she is tolerating activity well. However, the primary focus at this point should be on documenting her functional abilities and assessing her level of independence in performing ADLs safely.

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Correct Answer is C

Explanation

C. When the computer documentation system freezes, the first action the nurse should take is to notify the information services department of the situation. This allows the IT professionals to address the issue promptly and work on resolving the problem with the computer system.

A. Waiting for the system to reboot may lead to delays in documenting important patient information and could potentially affect the continuity of care. It's important to address the situation promptly to minimize any disruptions in patient care.

B. If the documentation system is unavailable for an extended period, identifying information as a late entry may be necessary to ensure that it is accurately recorded in the patient's record.

However, this should not be the first action taken, as there may be other immediate steps to address the situation.

D. While having a backup EMR is essential, printing it may not be the immediate solution. The focus should be on resolving the system freeze rather than relying solely on a printed backup.

A. Increase the lighting in the room. B. Obtain a new catheter. C. Clean the catheter with providone-iodine. D. Reposition the legs before reinsertion.

Correct Answer is B

Explanation

B. If the tip of the urinary catheter reemerges from the insertion site during insertion, it means that the catheter has become contaminated with microorganisms from the urethra or surrounding area. Continuing to insert the same catheter can introduce these microorganisms into the urinary tract, increasing the risk of urinary tract infection (UTI).

A. Increasing the lighting in the room allows for optimal visualization during the procedure, but it is not the priority action when the catheter has become contaminated.

C. Cleaning the catheter with providone-iodine is not sufficient to sterilize the catheter and eliminate the risk of introducing pathogens into the urinary tract.

D. Repositioning the legs before reinsertion does not address the contamination of the catheter and does not mitigate the risk of introducing pathogens into the urinary tract.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is entering a client's presenting problem when the computer documentation system freezes in the emergency department. Which action should the nurse perform first?

Correct Answer is C

Explanation

The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Correct Answer is B

Explanation

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