A nurse is caring for a client who ingested a poison and is now having seizures.
Which of the following is the priority action the nurse should take?
Maintain the patency of the client's airway.
Identify the poison the client ingested.
Measure the client's blood pressure.
Position the client on her side.
The Correct Answer is A
Choice A rationale:
"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.
Choice B rationale:
"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.
Choice C rationale:
"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.
Choice D rationale:
"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Drinking something cold can lower the oral temperature temporarily. When a person consumes something cold, the blood vessels in the mouth can constrict, leading to a lower temperature reading. However, it's important to note that this effect is temporary.
Choice B rationale:
Exercising can increase blood circulation and raise body temperature. However, immediately after intense physical activity, the body might start sweating, leading to a temporary drop in temperature. Prolonged or moderate exercise, on the other hand, generally increases body temperature.
Choice C rationale:
An outdoor temperature of 99°F does not directly affect body temperature. Body temperature is regulated internally and does not fluctuate based on external temperatures unless the person is exposed to extreme conditions for a prolonged period.
Choice D rationale:
A cold climate might lower skin temperature, but it does not necessarily reduce the body's core temperature significantly. The body has mechanisms to conserve heat in colder environments.
Choice E rationale:
Physical inactivity can lower body temperature, especially in situations where the person is sedentary for an extended period. Reduced physical activity can slow down metabolic processes, leading to a lower body temperature.
Correct Answer is D
Explanation
Choice B rationale:
Call for additional staff to assist with the transfer. The nurse's priority in this situation is ensuring the safety of the client during the transfer from the chair to the bed. Calling for additional staff provides the necessary support to safely move the client, minimizing the risk of falls or injuries. It is crucial to have an adequate number of staff members to assist in transfers, especially when the client's mobility is compromised.
Choice A rationale:
Obtain a walker for the client to use to transfer back to bed. While a walker can be helpful for mobility, the client has already asked to return to bed, indicating the immediate need for assistance. Waiting to obtain a walker could delay the transfer, potentially putting the client at risk.
Choice C rationale:
Use a transfer belt and assist the client back into bed. Using a transfer belt is a suitable technique for assisting clients with mobility. However, the nurse's priority in this scenario is to ensure there is enough staff assistance to guarantee a safe transfer. The nurse should not attempt to perform the transfer alone, even with a transfer belt, as it might be unsafe for both the nurse and the client.
Choice D rationale:
Determine the client's ability to help with the transfer. While assessing the client's ability to participate in the transfer is important, it is not the nurse's priority in this situation. The immediate concern is to secure adequate assistance to safely move the client back to bed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.