A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Place their arms around the client to prevent the fall.

Remain upright as the client fails toward them.

Move quickly to a position in front of the client.

Allow the client to slide down their outstretched leg.

Answer and Explanation

The Correct Answer is D

A. This action may increase the risk of injury to both the nurse and the client.

B. This action does not effectively prevent the fall or minimize injury.

C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.

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Correct Answer is D

Explanation

A. While a prescription may be necessary, attempting less restrictive alternatives should be the first action.
B. Documentation is important but should not precede attempting less restrictive alternatives.
C. Education about the use of restraints is important but should follow attempts at less restrictive alternatives.
D. The nurse should exhaust all possible alternatives to restraints before considering their use, in line with the principle of least restrictive intervention.

A. Notify the facility's risk management team. B. Assess the client for a change in condition. C. Place an incident report in the client's electronic medical record. D. Administer an antidote before notifying the provider.

Correct Answer is B

Explanation

A. While it may be necessary to notify risk management eventually, the immediate priority is to ensure the client's safety and well-being.
B. The nurse should promptly assess the client for signs and symptoms of an allergic reaction and initiate appropriate interventions as necessary.
C. Documentation of the medication error and allergic reaction should be completed after ensuring the client's immediate needs are addressed.
D. Administering an antidote may be appropriate in certain situations, but the nurse should first assess the client's condition and follow established protocols for managing allergic reactions.

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A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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