When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Provide a box of tissues for the client to use when coughing.

Assist the client in changing into a fresh hospital gown.

Teach the client to cover the mouth with hands when coughing.

Obtain face masks for staff to wear upon entering the room.

Answer and Explanation

The Correct Answer is A

A. Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B. Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C. Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D. Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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Correct Answer is D

Explanation

A. Hemoglobin (Hgb) and Hematocrit (Hct) are important indicators of anemia, which can be caused by nutritional deficiencies such as iron, vitamin B12, or folate deficiencies. For an older adult female, the reference range for hemoglobin is 12 to 16 g/dL, and the hematocrit range is 37% to 47%. A hemoglobin of 11.8 g/dL and a hematocrit of 34% are below the normal range, indicating potential anemia, which could be related to nutritional deficiencies.
B. Weight loss or being underweight can be a sign of nutritional deficiency, particularly if it is unintentional. However, this option lacks specific details about the extent of weight loss and its relation to other indicators. Weight alone does not provide complete information about nutritional deficiencies without additional context, such as changes in weight over time or body composition.
C. A decrease in lean body mass can be indicative of malnutrition or a prolonged deficiency in protein or overall caloric intake. While it is an important indicator of nutritional status, it reflects long-term changes and may not immediately show acute deficiencies.
D. Serum albumin and serum transferrin are biomarkers of nutritional status. The reference range for serum albumin is 3.5 to 5.0 g/dL, and for serum transferrin, it is 250 to 380 mg/dL. A serum albumin level of 3 g/dL and a serum transferrin level of 180 mg/dL are both below the normal range, indicating possible malnutrition or protein deficiency.

A. Provide frequent rest periods for the client. B. Allow additional time to complete tasks. C. Place assistive devices within reach. D. Speak slowly and distinctly to the client.

Correct Answer is C

Explanation

A. Providing frequent rest periods is important for older adults, especially those who may be experiencing fatigue or have chronic conditions. However, this intervention, while supportive, is not always the most critical or directly related to creating a therapeutic environment in all situations.
B. Allowing additional time for tasks is crucial for older adults who may have slower cognitive or physical processes. This approach helps reduce stress and frustration, contributing to a more supportive and therapeutic environment.
C. Placing assistive devices within reach is essential for ensuring safety and promoting independence. It helps older adults perform tasks more easily and reduces the risk of falls or accidents. This intervention is crucial for creating a therapeutic environment as it directly impacts the client’s ability to manage their own care and environment effectively.
D. Speaking slowly and distinctly is important for effective communication, especially if the older adult has hearing or cognitive impairments. It helps ensure that the client understands instructions and information, which is fundamental for their safety and engagement in their care.

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When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

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