A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

Check the client for injuries.

Obtain a prescription for medication to sedate the client.

Call the family and ask them to make arrangements for someone to sit with the client.

Assist the client back into bed and apply restraints.

Answer and Explanation

The Correct Answer is A

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

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Correct Answer is ["A","D","E"]

Explanation

These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.

Applying heat to the client's ankle is not recommended as it can increase swelling and inﬂammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the aﬀected area.

A. The weights rest against the foot of the bed. B. The ropes are in the center of the wheel grooves. C. The weights are equal on each side. D. The ropes atach securely to the pin

Correct Answer is A

Explanation

If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or ﬂoor. This ensures that the traction is providing the appropriate amount of force to the aﬀected limb.

The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.

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A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?

Correct Answer is A

Explanation

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