A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?

Place the client's valuables in the facility's safe.

Observe the client's level of mobility.

Administer prescribed medications.

Electronically enter the prescriptions from the provider.

Answer and Explanation

The Correct Answer is B

A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.

B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.

C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.

D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.

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Correct Answer is A

Explanation

- A: A heart rate greater than 60/min indicates that the transcutaneous pacing is effectively maintaining a heart rate within a normal range, which is crucial for adequate cardiac output and systemic perfusion.
- B: While 2+ pedal pulses indicate good peripheral perfusion, they do not directly reflect the effectiveness of transcutaneous pacing in treating complete heart block.
- C: Pacer spikes should appear before the QRS complex to show that the pacing stimulus is being delivered appropriately. Spikes after the QRS complex suggest that the pacing is not capturing the heart effectively.
- D: Distended jugular veins would be more indicative of heart failure or fluid overload and do not directly relate to the effectiveness of pacing therapy.

A. The client tucks his chin while swallowing food. B. The client sits upright in bed during meals. C. The client pockets food on one side of his mouth. D. The client has a cough reflex.

Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective?

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

Correct Answer is C

Explanation

A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take?

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