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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

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.

A. Place the arm across the client’s chest to support the wrist. B. Use a wrist restraint to decrease mobility in the arm. C. Apply an arm board to immobilize the wrist. D. Instruct client to limit use of that arm.

Correct Answer is C

Explanation

This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.

Some additional information for the response are:

Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.

Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.

Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.

Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).

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A client with dysphagia is eating breakfast and suddenly slumps over. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A client with difficult venous access has an intravenous insertion site located at the bend of the wrist. Which action would be most appropriate for a nurse to take?

Correct Answer is C

Explanation

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