A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Inform the client's family member.

Notify the client's provider.

Assist the client back into bed.

Answer and Explanation

The Correct Answer is A

A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signs provides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.

B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.

C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.

D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.

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Correct Answer is B

Explanation

A. Concurrent treatment for GERD:

This is not typically a contraindication for hormone replacement therapy (HRT). GERD treatment is not directly related to the decision to use HRT.

B. History of breast cancer:

This is a contraindication for HRT. Estrogen replacement therapy has been associated with an increased risk of breast cancer. Therefore, individuals with a history of breast cancer are generally advised against using HRT.

C. History of dermatitis:

A history of dermatitis is not a contraindication for HRT. However, the decision to use HRT should be made based on a comprehensive assessment of the client's overall health and risk factors.

D. Multiple hospitalizations for COPD:

While COPD itself is not a contraindication for HRT, decisions about HRT should consider the individual's overall health status and potential risks. Factors such as smoking history and respiratory function may be considered in the assessment.

A. Inject the medication deep into the thigh muscle. B. Easy bruising indicates the medication is effective. C. Expect stools to become black and tarry. D. Use a soft bristle toothbrush.

Correct Answer is D

Explanation

A. Inject the medication deep into the thigh muscle.

This statement is incorrect for subcutaneous heparin administration. Heparin is typically administered subcutaneously in the fatty tissue just under the skin, not into the muscle. Intramuscular injection is not appropriate for heparin.

B. Easy bruising indicates the medication is effective.

This statement is inaccurate. Easy bruising is not an indicator of the effectiveness of heparin. In fact, excessive bruising can be a side effect of anticoagulant therapy, indicating a potential issue with bleeding or clotting.

C. Expect stools to become black and tarry.

This statement is more relevant to medications like iron supplements or upper gastrointestinal bleeding. It is not a common side effect of subcutaneous heparin.

D. Use a soft bristle toothbrush.

This statement is correct. It is important for individuals on anticoagulant therapy, such as heparin, to use a soft bristle toothbrush to minimize the risk of bleeding and gum irritation. Hard bristle toothbrushes can cause gum bleeding, especially in individuals with a tendency for bleeding due to anticoagulant use.

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A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing menopausal symptoms and requests information about hormone replacement therapy (HRT). Which of the following items in the client's health history is a contraindication for hormone replacement therapy?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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