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
Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.
This set of vital signs is cause for concern because the blood pressure is significantly elevated.
A blood pressure reading of 196/114 mmHg is considered a hypertensive crisis and requires immediate medical attention.
Choice A) Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg is within normal limits for an adult.
Choice C) Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg is also within normal limits for an adult.
Choice D) Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg is slightly elevated but not cause for immediate concern.
Correct Answer is D
Explanation
Encouraging bed rest would be an inappropriate nursing intervention to promote mobility for a client with decreased mobility.
Bed rest can lead to further complications of immobility1.
Choice A is not an answer because teaching the client to do active range of motion (AROM) exercises every 2 hours can help maintain joint mobility and muscle strength2.
Choice B is not an answer because evaluating the client’s need for ambulatory aids can help them move safely and independently1.
Choice C is not an answer because keeping skin clean and dry is important for preventing skin breakdown, which can be a complication of immobility1.
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