A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first?
Place the client's valuables in the facility's safe.
Observe the client's level of mobility.
Administer prescribed medications.
Electronically enter the prescriptions from the provider.
The Correct Answer is B
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Influenza immunizations: This is an example of primary prevention because it aims to prevent the occurrence of influenza infection in the first place.
B. Tuberculosis screenings: This is an example of secondary prevention because it involves early detection and treatment of tuberculosis infection to prevent its progression to active disease and
transmission to others.
C. Presentations about safer sex practices: This is an example of primary prevention aimed at reducing the risk of sexually transmitted infections by promoting safe behaviors.
D. Evaluations of bloodborne pathogen policies: This is an administrative activity related to ensuring workplace safety and adherence to policies and procedures and does not directly
involve prevention of communicable diseases among individuals.
Correct Answer is D
Explanation
A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
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