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?

Notify the client's provider.

Measure the client's vital signs.

Document the fall in the client's medical record.

Complete an incident report.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the provider follows assessment; vital signs gauge injury first. Immediate stability check precedes communication in a fall scenario like this.

Choice B reason: Measuring vital signs first assesses for shock, injury, or distress post-fall. It’s the priority to ensure safety before further actions in emergencies.

Choice C reason: Documentation is essential but secondary to client stability. Vital signs determine urgency, so recording waits until immediate health risks are evaluated.

Choice D reason: Incident reports address safety trends, not acute care. Assessing vital signs first ensures the client’s condition guides subsequent reporting and intervention.

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Correct Answer is D

Explanation

Choice A reason: Cantaloupe is potassium-rich, about 400 mg per cup, due to its fruit sugar content. It’s unsuitable for low-potassium diets, as it elevates serum levels significantly.

Choice B reason: Orange juice contains around 500 mg potassium per cup, a high amount. Its citric nature doesn’t offset this, making it inappropriate for potassium restriction.

Choice C reason: Sweet potato has over 500 mg potassium per serving, concentrated in its starchy flesh. It’s a poor choice for minimizing potassium in electrolyte imbalances.

Choice D reason: Baked chicken breast offers less than 300 mg potassium per serving, far lower than fruits or tubers. It’s the best option for a low-potassium diet here.

A. New onset of hearing loss B. Slurred speech C. Constipation D. Hypotension

Correct Answer is A

Explanation

Choice A reason: Hearing loss is a known gentamicin ototoxicity effect, damaging cochlear hair cells irreversibly. Scientifically, this aminoglycoside targets the inner ear, causing tinnitus or deafness, a critical adverse reaction to monitor in pyelonephritis treatment per pharmacology evidence.

Choice B reason: Slurred speech suggests neurological issues (e.g., stroke), not gentamicin effects. Scientifically, this drug affects kidneys and ears, not speech centers, making this unrelated to its toxicity profile, which focuses on auditory and renal damage.

Choice C reason: Constipation isn’t linked to gentamicin; it’s more typical of opioids or immobility. Scientifically, this antibiotic’s side effects center on nephrotoxicity and ototoxicity, not gastrointestinal motility, rendering this an unlikely adverse reaction in this context.

Choice D reason: Hypotension may occur with rapid IV gentamicin, but it’s less common than ototoxicity. Scientifically, hearing loss is a hallmark toxicity, outweighing transient blood pressure drops, which are manageable and less specific to this drug’s adverse profile.

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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 teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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