A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?

Check the client's ability to use the call light.

Document the client's risk in the medical record.

Request a referral for physical therapy

Place a gait belt in the client's room.

Answer and Explanation

The Correct Answer is A

The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.

Explanation for the other options:

b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.

c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.

d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.

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Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

A. Oil-based lubricant B. Enteric feeding pump C. Sterile gloves D. pH strips

Correct Answer is D

Explanation

a. Oil-based lubricant

Explanation:

The correct answer is a. Oil-based lubricant.

When preparing to insert a nasogastric tube for gastric decompression, the nurse should obtain an oil- based lubricant. Lubricating the nasogastric tube before insertion helps facilitate smooth passage through the nasal passages and into the stomach, reducing discomfort and potential trauma to the client.

Option b, an enteric feeding pump, is not necessary for the insertion of a nasogastric tube for gastric decompression. An enteric feeding pump is used for administering enteral feedings, which is a diﬀerent procedure and indication

Option c, sterile gloves, may be needed depending on the facility's policy and the specific circumstances of the client. While maintaining aseptic technique is important during the procedure, sterile gloves may not always be required for nasogastric tube insertion. Clean gloves or a clean hand hygiene practice may be sufficient in some cases.

Option d, pH strips, are not typically needed for nasogastric tube insertion for gastric decompression. pH strips are more commonly used to check the acidity or alkalinity of body ﬂuids, such as gastric aspirate, to confirm placement of the nasogastric tube in the stomach.

By obtaining an oil-based lubricant, the nurse ensures the appropriate preparation for the nasogastric tube insertion, promoting the client's comfort and safety during the procedure.

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A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?

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