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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Correct Answer is B

Explanation

A. Salmeterol:

Salmeterol is a long-acting beta-agonist bronchodilator used for respiratory conditions. While it does not directly cause sedation, the individual response may vary, and caution should be taken if the client experiences dizziness or lightheadedness.

B. Diazepam:

Diazepam is a medication that belongs to the benzodiazepine class and can cause sedation, drowsiness, and impaired coordination. These side effects increase the risk of falls, especially in older adults. Fall precautions may include measures such as bed alarms, non-skid socks, and close monitoring when the client is ambulating.

C. Misoprostol:

Misoprostol is a medication used to prevent gastric ulcers, and it does not typically cause sedation or affect coordination.

D. Penicillin G:

Penicillin G is an antibiotic and does not have sedative effects that would necessitate fall precautions.

A. Apply petroleum jelly around and inside the nares. B. Cleanse the mask or collar with soapy water every other day. C. Make sure the straps on the mask are secure but not too tight. D. Post "no smoking" warning signs at home in a prominent location. E. Check the tops of his ears regularly for skin breakdown.

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.

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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

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

Explanation

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