Fundamentals A

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information. Cognitive abilities vary between individuals. Rather than expecting misunderstanding, the nurse should assess the client's cognition and ability to learn, teach accordingly, and verify understanding. The nurse should explore the client's past experiences and use them to establish connections to new knowledge. It is helpful when working with older adult clients to invite another household member to the teaching session so that person can help reinforce new information later. The nurse should also honor the client's preference for either one-on-one or group settings.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this." An effective coping strategy is talking with others in the family and supporting each other. This statement displays effective coping skills because the family is using social supports to assist them throughout the grief process.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate lung sounds The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath. The nurse should measure urine output to monitor the renal function of an older adult client who is receiving IV fluid; however, it is not the priority assessment. The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of an older adult client who is receiving IV fluid; however, it is not the priority assessment. The nurse should monitor serum electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances in an older adult client who is receiving IV fluid; however, it is not the priority assessment.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Typically, a client's urine specific gravity is greater than 1.030 in the presence of fluid-volume deficit. Neck vein distension is a clinical manifestation of fluid-volume excess. Hypotension is an expected finding for a client who has fluid-volume deficit.

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?

Use a clock pattern to describe food on the client's plate Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals. Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate swallowing without choking. Large-handle adaptive utensils are easier for the client to grip and allow for greater independence during meals for clients who have vision loss. The nurse should allow the client to decide for herself the order in which she consumes food.