A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Explain the rounding schedule to the client

Tell the client about the visiting hours

Review meal options with the client.

Place the call light within reach of the client.

Answer and Explanation

The Correct Answer is D

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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Correct Answer is D

Explanation

A. Hyperglycemia: Albuterol is not prescribed to manage blood glucose levels. While it can sometimes cause a mild increase in blood glucose as a side effect, its primary therapeutic action is not directed at treating hyperglycemia or any diabetic conditions.

B. Swelling of the lips: Swelling of the lips could indicate an allergic reaction or angioedema, which is a medical emergency. Albuterol is not used to treat allergic swelling; epinephrine would be the medication of choice in managing severe allergic reactions or anaphylaxis.

C. Nausea: Albuterol is not intended to treat nausea. Although gastrointestinal upset, including nausea, can sometimes occur as a side effect of albuterol, it is not administered for the purpose of controlling nausea in clients.

D. Shortness of breath: Albuterol is a short-acting beta2-agonist that works by relaxing bronchial smooth muscle, leading to bronchodilation. It is commonly prescribed to relieve acute episodes of shortness of breath, wheezing, or bronchospasm, particularly in asthma or COPD.

A. Discontinue use of electronics 30 min before bedtime. B. Drink a cup of coffee 1 hr before bedtime. C. Consume a meal 1 hr before bedtime. D. Exercise 1 hr before bedtime.

Correct Answer is A

Explanation

A. Discontinue use of electronics 30 min before bedtime: The use of electronics before bedtime can disrupt the body's natural sleep cycle by suppressing melatonin production. Stopping electronic use at least 30 minutes before bed promotes relaxation and better sleep quality.

B. Drink a cup of coffee 1 hr before bedtime: Caffeine is a stimulant that can interfere with falling asleep and maintaining deep sleep. Consuming coffee close to bedtime would likely worsen sleep disturbances rather than help.

C. Consume a meal 1 hr before bedtime: Eating a large meal close to bedtime can cause discomfort, indigestion, and difficulty falling asleep. Light snacks are acceptable, but heavy meals should be avoided before sleeping.

D. Exercise 1 hr before bedtime: Vigorous exercise shortly before bedtime can increase adrenaline and body temperature, making it harder to fall asleep. Exercise is better scheduled earlier in the day to support restful sleep.

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A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Nursing Test Bank

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