A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
Fall history.
Medical diagnosis.
Use of assistive devices.
Mental status.
Do-not-resuscitate status.
Correct Answer : A
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A suffix is a word part that is added to the end of a root word to modify its meaning. For example, in the medical term "cardiologist," the suffix '-ologist' means a specialist or expert. A suffix is placed at the end of a root word or a combining form to create a specific medical term.
Choice B rationale:
A word root is the foundational part of a medical term. It contains the core meaning of the term and is not usually modified by prefixes or suffixes. For instance, in the term "cardiology," 'cardi-' is the word root, representing the heart. Word roots provide the essential meaning of the medical term.
Choice C rationale:
A prefix is a word part that is added to the beginning of a root word or a combining form to modify its meaning. Prefixes are important in medical terminology as they indicate locations, numbers, or time. For example, in the term "prehypertension," the prefix 'pre-' means before. Prefixes are added at the beginning of a word.
Choice D rationale:
A combining form is a word root combined with a vowel (usually 'o') that can be joined with other word parts to create a medical term. Combining forms are used as a connector to join a root word and a suffix or another root word. For example, in the term "gastritis," 'gastr-' is the combining form, representing the stomach. Combining forms facilitate the construction of complex medical terms.
Correct Answer is C
Explanation
The correct answer is choice C: Move any clients to safety.
Choice C rationale: The nurse's priority is always client safety. In the event of an electrical issue that poses a potential risk, such as smoke or fire, the nurse should first ensure that any clients in the area are moved to a safe location. This aligns with the widely-used RACE acronym for fire response (Rescue, Alarm, Confine, Extinguish), which highlights the importance of removing individuals from danger before attending to other aspects of fire safety.
Choice A rationale: Using a fire extinguisher is an appropriate action to take when dealing with a small, manageable fire. However, in this scenario, ensuring client safety takes precedence over attempting to extinguish the source of the smoke. This is also in line with the RACE mnemonic, which emphasizes the importance of prioritizing evacuation.
Choice B rationale: Activating the fire alarm is an important step to alert others in the building about a potential fire and the need for evacuation. However, the priority remains client safety, so moving clients to a safe location should be the nurse's initial response, following the RACE acronym.
In summary, the nurse's priority action when encountering an electrical hazard is to move clients to safety. After ensuring client safety, the nurse can then activate the fire alarm and, if trained to do so, use a fire extinguisher on the outlet if necessary. This approach aligns with the RACE mnemonic, which serves as a guideline for fire response.
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