A client begins to fall while the nurse is assisting with ambulation. What is the priority nursing intervention?
Initiate a code.
Call the charge nurse.
Guide the client safely to the floor.
Call the client's doctor.
The Correct Answer is C
The priority nursing intervention when a client begins to fall while ambulating is to guide the client safely to the floor.
This can help prevent injury and ensure the safety of the client.

CHOICE A. Initiating a code is not necessary for this situation as it is not a medical emergency.
CHOICE B AND D : Calling the charge nurse or the client’s doctor may be appropriate after the client has been safely guided to the floor and their condition has been assessed
[B] [D].
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Asking “What types of food do you eat for meals and between meals?” is considered a culturally sensitive question because it shows respect for the individual’s dietary habits and preferences.
Choice A is not correct because asking “Are you required to pray in a certain way at certain times?” may come across as intrusive or judgmental.
Choice C is not correct because asking “Are you familiar with the way we prepare meals?” may come across as presumptuous or dismissive of the individual’s cultural background.
Choice D is not correct because asking “Are you okay with not having kosher meals?” may come across as dismissive of the individual’s dietary needs or religious beliefs.
Correct Answer is C
Explanation
The priority responsibility of the nurse is to call for a Cambodian interpreter.
This ensures that the mother’s needs and concerns are accurately communicated and understood.
It also helps to prevent any misunderstandings or miscommunications that could occur if the daughter were to interpret.
Choice A is not an appropriate response because calling the chaplain for support may not address the language barrier.
Choice B is not an appropriate response because allowing unlicensed assistive personnel to interpret could result in inaccurate or incomplete information being conveyed.
Choice D is not an appropriate response because continuing to work with the daughter for interpretation could result in misunderstandings or miscommunications.
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