The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago.
Which assessment should the nurse complete first?

Oxygen saturation measurement.

Review of current medications.

Intake and output last 24 hours.

Use of hearing aids or glasses.

Answer and Explanation

The Correct Answer is A

This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.

Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.

Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.

Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.

Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.

Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.

Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.

The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.

Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.

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Correct Answer is A

Explanation

Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.

This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.

The nurse should intervene and use a manual BP cuff with a stethoscope instead.

Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.

Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.

The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.

Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.

Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.

A. Wipe from the outer part of the eye toward the inner portion. B. Rinse the washcloth before washing the second eye. C. Ask the client to roll the eyes upward. D. Use a fresh washcloth when cleaning each eye.

Correct Answer is D

Explanation

Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.

The other choices are wrong because:

Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.

Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.

Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.

Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.

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The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago. Which assessment should the nurse complete first?

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Correct Answer is D

Explanation

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The nurse is assessing an elderly client who has become confused since admission to the hospital two days ago.
Which assessment should the nurse complete first?