A client with dysphagia is eating breakfast and suddenly slumps over. What should the nurse do first?
Call the rapid response team.
Move the client to the bed.
Call the primary care provider.
Assess client for unresponsiveness.
The Correct Answer is D
This is because the nurse should always follow the ABC (airway, breathing, circulation) priority when dealing with a client who suddenly slumps over. The nurse should check if the client is conscious and breathing before calling for help or moving the client.
Choice A is wrong because calling the rapid response team should not be done before assessing the client’s condition and ensuring a patent airway.
Choice B is wrong because moving the client to the bed may cause further harm or aspiration if the client has food in the mouth or airway.
Choice C is wrong because calling the primary care provider is not a priority action in this situation. The nurse should first assess and stabilize the client before notifying the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can
cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.
These are normal signs of wound healing and do not indicate infection or complications.
Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.
Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.
Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.
Correct Answer is B
Explanation
This is because anti-embolism stockings are designed to prevent swelling and blood clots in the legs by applying graduated compression, which is tighter around the ankle and looser as it moves up the leg. Applying the stockings in the morning before any swelling occurs ensures a proper fit and optimal blood flow.
Choice A is wrong because massaging the legs can dislodge a blood clot and cause a pulmonary embolism.
Choice C is wrong because wetting the stockings can make them harder to apply and reduce their effectiveness.
Choice D is wrong because removing the stockings before bathing can increase the risk of swelling and clotting, and applying fresh ones afterward can be difficult and uncomfortable.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.