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A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

The nurse should place his or her feet close together side by side to make themselves have a good center of gravity to assist the patient to the floor.

The nurse should rock his or her pelvis out and try to hold the patient up to prevent falling.

The nurse should grasp the gait belt and push the client’s body backward away from his or her body.

The nurse should use the patients gait belt to gently slide the client down his or her body to the floor.

Answer and Explanation

The Correct Answer is D

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

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Correct Answer is A

Explanation

A. Use standard precautions in caring for all clients:

Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.

B. Place all post-surgical clients in contact isolation:

Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.

C. Order IV antibiotics for all clients with sacral pressure wounds:

Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.

D. Limit visitations to 2 people a day for each client:

While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.

A. Systolic pressure B. Pulse pressure C. Auscultatory gap D. Diastolic pressure

Correct Answer is D

Explanation

A. Systolic pressure:

The first sound heard during blood pressure measurement corresponds to the systolic pressure, the pressure in the arteries when the heart is contracting.

B. Pulse pressure:

Pulse pressure is the numerical difference between the systolic and diastolic pressures but is not specifically represented by a sound in blood pressure measurement.

C. Auscultatory gap:

An auscultatory gap is a temporary disappearance of sounds during blood pressure measurement, typically occurring between the systolic and diastolic pressures. It is not directly associated with the second sound.

D. Diastolic pressure:

The second sound heard corresponds to the closure of the aortic valve, marking the beginning of diastole. This sound represents the diastolic pressure, which is the pressure in the arteries when the heart is at rest.

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A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

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