A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Complete an incident report.

Notify the client's provider.

Document the fall in the client's medical record.

Measure the client's vital signs.

Answer and Explanation

The Correct Answer is D

The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.

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Correct Answer is B

Explanation

The correct answer is B. Encourage the client to be assertive. Dependent personality disorder is characterized by excessive reliance on others for emotional and practical support, fear of abandonment, difficulty expressing disagreement, and low self-esteem. The nurse should instruct the caregiver to help the client develop autonomy and self-confidence by encouraging them to express their opinions, make their own choices, and take responsibility for their actions.

A. Can be a result of a paralytic ileus B. Indicates decreased motility C. Sounds are soft and at a rate of 1/min D. Sounds are high-pitched

Correct Answer is D

Explanation

The correct answer is D. Hyperactive bowel sounds are high-pitched and occur at a rate of more than 30/min. They indicate increased motility and can be a result of diarrhea, inflammation, infection, or bleeding.

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A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in theteaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?

A nurse is reinforcing teaching with a client who has diabetes mellitus about a 24-hr creatinine clearance test. Which of the following statements should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan?

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is starting digoxin therapy to treat heart failure. The nurse should reinforce with the client that which of the following adverse effects is a possible indication of digoxin toxicity and should be reported to the provider?

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. For which of the following adverse effects should the nurse instruct the client to monitor and report to the provider?

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

A nurse determines that clients who receive zolpidem postoperatively have an increased fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings?