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 ["A","C","E","F"]

Explanation

A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.

B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.

However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.

A. Use sterile gloves to obtain the sputum specimen. B. Place the sputum specimen in a clean container. C. Collect the sputum specimen in the morning. D. Obtain the sputum specimen after the client uses mouthwash.

Correct Answer is C

Explanation

A. Sterile gloves are not necessary for collecting sputum specimens. Clean gloves are typically sufficient.

B. Sputum specimens should be collected in a sterile container to prevent contamination.
C. Early morning specimens are preferred due to increased sputum production from the overnight accumulation of secretions.
D. Mouthwash may contain substances that interfere with sputum culture results, so specimens should be collected before mouthwash use.

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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

Correct Answer is ["A","C","E","F"]

Explanation

A nurse is preparing to collect a sputum specimen from a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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