A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Inform the client's family member.

Notify the client's provider.

Assist the client back into bed.

Answer and Explanation

The Correct Answer is A

A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signs provides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.

B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.

C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.

D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

Apply petroleum jelly around and inside the nares:

Petroleum jelly is not recommended for use with oxygen therapy. It can be flammable and may increase the risk of fire when in contact with oxygen.

B. Cleanse the mask or collar with soapy water every other day:

While it's important to keep the oxygen equipment clean, using soapy water might not be suitable for all types of oxygen masks or collars. Specific cleaning instructions provided by the supplier or healthcare provider should be followed to ensure proper hygiene and maintenance of the equipment.

C. Make sure the straps on the mask are secure but not too tight:

Proper fitting of the oxygen mask is crucial for comfort and adequate oxygen delivery. The straps should be secure enough to hold the mask in place but not so tight as to cause discomfort or skin irritation.

D. Post "no smoking" warning signs at home in a prominent location:

Oxygen is highly combustible, and smoking near oxygen can lead to fires or explosions. It's crucial to have clear warning signs in the home to prevent smoking in areas where oxygen is used.

E. Check the tops of his ears regularly for skin breakdown:

Prolonged use of oxygen masks or nasal cannulas can cause skin breakdown, particularly around the ears where the tubing or mask straps may rest. Regular checks for any signs of skin breakdown are essential for early detection and prevention.

A. Place the child in prone position. B. Restrain the child. C. Place a tongue depressor in the child's mouth. D. Clear the area of hard objects. E. Loosen restrictive clothing.

Correct Answer is ["D","E"]

Explanation

A. Place the child in prone position:

Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.

B. Restrain the child:

Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.

C. Place a tongue depressor in the child's mouth:

It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.

D. Clear the area of hard objects:

Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.

E. Loosen restrictive clothing:

Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.

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A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce which of the following instructions with the client and his family? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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