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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
Correct Answer is B
Explanation
This is because the resident is independent and sociable, and has the right to choose her own grooming preferences.
Serving her breakfast in her room will respect her autonomy and dignity, and prevent her from missing a meal.
Choice A is wrong because omitting her breakfast will deprive her of nutrition and hydration, and may cause health problems.
It will also violate her rights as a resident.
Choice C is wrong because getting her up early enough to be ready for breakfast will disrupt her sleep cycle and may cause fatigue or stress.
It will also impose the nurse’s values on the resident, and disregard her preferences.
Choice D is wrong because having her go to breakfast regardless of the state of her grooming will embarrass her and lower her self-esteem.
It will also disrespect her culture and values, and may affect her social interactions.
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