A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?
Assist the client back into bed.
Notify the client’s provider.
Inform the client’s family member.
Obtain the client’s vital signs.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Assisting the client back into bed is not the initial action. Moving the client without assessing their condition could potentially cause harm.
Choice B rationale:
Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.
Choice C rationale:
Informing the client’s family member is not the immediate priority. The nurse should first ensure the client’s safety and assess their condition.
Choice D rationale:
Obtaining the client’s vital signs is the initial action. This helps assess the client’s current condition and determine if there are any immediate medical needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.
Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.
The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.
Choice B rationale:
Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.
Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.
Choice C rationale:
Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.
If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.
Choice D rationale:
Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.
Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.
Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.
Choice E rationale:
Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.
It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.
Correct Answer is B
Explanation
Choice A rationale:
Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.
Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.
The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.
Choice B rationale:
Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.
These actions close off the airway and open the esophagus, creating a smoother path for the tube.
The nurse should instruct the patient to perform these actions during insertion to promote successful placement.
Choice C rationale:
While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.
Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.
The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.
Choice D rationale:
Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).
This landmark-based method provides a more reliable estimation of the distance to the stomach.
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