A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Explain the rounding schedule to the client

Tell the client about the visiting hours

Review meal options with the client.

Place the call light within reach of the client.

Answer and Explanation

The Correct Answer is D

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

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Correct Answer is C

Explanation

A. Encourage visits from family members: While family presence can help reduce anxiety and reorient clients with delirium, it is not the immediate first step. Before implementing supportive strategies, the nurse must first assess the client’s neurological status to determine the severity and possible cause of the delirium.

B. Administer an anxiolytic medication: Administering medications should not be the first action because delirium can be caused by multiple reversible factors. Sedating a client without identifying the underlying cause may worsen confusion or mask important symptoms that need immediate intervention.

C. Determine the client's level of consciousness: Assessing the client’s level of consciousness is the priority because it provides critical information about the severity of the delirium and helps guide immediate and appropriate interventions. Early assessment ensures that life-threatening conditions, such as hypoxia or sepsis, are not overlooked.

D. Keep lights on in the client's room: Maintaining a well-lit environment can help prevent disorientation, especially at night, but it is a secondary supportive measure. Assessment of mental status must occur first to prioritize safety and identify urgent medical needs.

Correct Answer is []

Explanation

Prepare the client for an emergency cesarean birth: Emergency cesarean delivery is indicated in cases of fetal distress or placenta previa with severe bleeding at term. In a hydatidiform mole, there is no viable fetus, and the priority is evacuation of the molar tissue rather than delivery by cesarean section.
Prepare the client for suction curettage: Suction curettage is the treatment of choice for a hydatidiform mole. It allows for the complete evacuation of abnormal trophoblastic tissue, preventing complications such as severe hemorrhage and progression to malignant gestational trophoblastic disease.
Anticipate a prescription for methotrexate: Methotrexate is primarily used to treat ectopic pregnancies or persistent gestational trophoblastic disease after a molar pregnancy, not for initial management. Immediate evacuation of the mole by suction curettage is the first-line intervention for this client.
Remind the client that weekly blood tests are needed to measure pregnancy hormone: Following a molar pregnancy, weekly beta-hCG tests are critical to monitor for residual trophoblastic tissue or the development of choriocarcinoma. A declining beta-hCG confirms the resolution of disease, while a plateau or rise indicates persistent disease.
Administer terbutaline: Terbutaline is a tocolytic medication used to relax the uterus in cases of preterm labor. In the case of a hydatidiform mole, uterine evacuation is necessary rather than uterine relaxation, making terbutaline inappropriate for this situation.
Vaginal bleeding: Clients with a hydatidiform mole are at risk for significant vaginal bleeding due to the abnormal growth of trophoblastic tissue. Monitoring the amount and type of vaginal bleeding helps detect hemorrhage or retained molar tissue requiring urgent intervention.
Blood pressure: Elevated blood pressure is a potential complication of hydatidiform mole, similar to preeclampsia, and can occur even in the first or second trimester. Regular monitoring of blood pressure is essential to detect worsening hypertensive symptoms early.
Uterus for hypertonicity: Hypertonicity of the uterus is typically monitored in cases of labor or uterine rupture concerns. In a hydatidiform mole, the uterus is distended by abnormal tissue but hypertonicity is not a primary concern needing monitoring in this condition.
Unilateral pelvic pain: Unilateral pelvic pain is more characteristic of ectopic pregnancy rather than a molar pregnancy. In hydatidiform mole, generalized uterine enlargement and discomfort are more typical, so unilateral pelvic pain is not a focus for this client.
Cervical dilation per provider: Cervical dilation is not the main indicator of progress or concern with a molar pregnancy. The focus is on removing molar tissue and monitoring beta-hCG levels, not on the progress of cervical changes like in labor.

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A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has acute delirium. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Correct Answer is []

Explanation

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