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.

Answer and Explanation

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. .

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Correct Answer is D

Explanation

Choice A rationale:

Healthcare-associated infections (HAIs) do not necessarily occur due to compromised immunity. HAIs refer to infections that patients acquire while receiving treatment for medical or surgical conditions, and they can happen to individuals with varying levels of immunity.

Choice B rationale:

While infections during therapeutic procedures are a concern, not all healthcare-associated infections occur during such procedures. HAIs can happen in various healthcare settings and not limited to therapeutic procedures.

Choice C rationale:

Inhaling pathogens in a healthcare setting might lead to infections, but not all healthcare-associated infections happen due to inhalation. HAIs can occur through different modes of transmission.

Choice D rationale:

Healthcare-associated infections (HAIs) occur when a patient acquires an infection while receiving care in a healthcare setting, including hospitals. This can involve various sources, such as contaminated medical equipment, surgical procedures, or interactions with healthcare personnel.

A. Every 45 minutes. B. Every 30 minutes. C. Every hour. D. Every 2 hours.

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

Explanation

Choice A rationale:

Family members who smoke must be at least 10 ft from the client when oxygen is in use. Oxygen supports combustion, and smoking near an oxygen source can lead to a fire. Keeping family members who smoke at a safe distance minimizes this risk.

Choice B rationale:

Nail polish remover or hair spray should not be used near a client who is receiving oxygen. These substances contain flammable ingredients, which can ignite in the presence of oxygen. Instructing the client and those around them to avoid using such products prevents potential accidents.

Choice C rationale:

A "No Smoking" sign should be placed on the front door. This serves as a visual reminder to visitors and family members that smoking is prohibited in the vicinity, reducing the risk of fire when oxygen is in use. Clear communication through signage is essential in maintaining a safe environment.

Choice E rationale:

A fire extinguisher should be readily available in the home. Despite precautions, accidents can still happen. Having a fire extinguisher nearby allows for immediate response in case of a fire-related emergency, ensuring the safety of the client and those around them.

Choice D rationale:

Cotton bedding and clothing should be replaced with items made from wool. This statement is incorrect. There is no specific requirement to replace cotton items with wool for a client using oxygen. Instead, the focus should be on fire safety measures and ensuring that flammable materials are kept away from the oxygen source.

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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?

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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?