A client complains of back pain after slipping and falling on a wet floor at the hospital. What is the nurses best first action to take?

notify the nurse administrator

clean up the spill

Ask the client to remain still

document the incident

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

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Correct Answer is B

Explanation

Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.

Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.

Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.

Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.

A. "We will use the antipsychotics around the clock" B. "She will not be left home alone C. "I will apply the restraint to only one wrist". D. "Rugs will be put in the bathroom to help her identify where she is "

Correct Answer is B

Explanation

Choice A Rationale: Using antipsychotics around the clock is not an appropriate approach for managing Alzheimer's disease and may have adverse effects.

Choice B Rationale: "She will not be left home alone" indicates effective teaching because it emphasizes the importance of supervision and safety for a client with Alzheimer's who may be at risk of wandering or accidents.

Choice C Rationale: Applying a restraint to only one wrist is not an appropriate or effective strategy for managing Alzheimer's-related behaviors and may have ethical concerns.

Choice D Rationale: Placing rugs in the bathroom may create tripping hazards for a client with Alzheimer's. Effective teaching should focus on removing hazards rather than adding them.

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A client complains of back pain after slipping and falling on a wet floor at the hospital. What is the nurses best first action to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

Correct Answer is B

Explanation

A nurse provides home safety education to the family of a client with moderate Alzheimer's. Which of the following statements made by the primary caregiver indicates effective teaching?

Correct Answer is B

Explanation

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? Select All that Apply

A nurse is offering teaching to a caregiver about urinary system complications that occur as a result of spinal cord injury. Which of the following will the nurse include in teaching?

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize which of the following as confabulation?

The client recently diagnosed with Guillain-Barre' syndrome is drooling and having difficulty swallowing secretions. When asked why this is happening, which of the following is the best answer for the nurse to give to the family?

A client diagnosed with severe Alzheimer's has been admitted to a long term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?

The nurse caring for the client with Alzheimer's documents that the client is in the early stage of Alzheimer's. Which findings are consistent with mild Alzheimer's disease?