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 C

Explanation

A. Clean gloves are typically sufficient for wound care, and the use of sterile gloves may not be necessary for routine dressing changes.
B. Frequent dressing changes can disrupt wound healing and increase the risk of infection. Dressings should be changed according to the healthcare provider's instructions, which are typically less frequent.
C. When cleaning the wound, it is important to start from the incision site and work outward to avoid introducing contaminants into the wound.
D. Tincture of benzoin is a skin adhesive and may not be routinely used for dressing changes, especially if it is not specified in the healthcare provider's orders.

A. Distended neck veins B. Postural hypotension C. Dependent edema D. Bradycardia

Correct Answer is B

Explanation

A. Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B. In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C. Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D. Bradycardia is not typically associated with extracellular fluid volume deficit.

Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.

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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?

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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?