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].
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Related Questions
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.
Correct Answer is B
Explanation
Background noise can interfere with the ability of a person with hearing loss to understand speech, even when wearing a hearing aid.
By turning off the television, the nurse can reduce background noise and improve communication with the client.
Choice A) Chewing gum is not an appropriate intervention to improve communication with a client who has hearing loss.
Choice C) Speaking loudly and clearly may help, but it is not as effective as reducing background noise.
Choice D) Using paper and pencil may be helpful in some situations, but it is not the most effective intervention to improve communication with a client who is wearing a hearing aid.
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