A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Lean the client toward the wall.

Assume a narrow base of support.

Lower the client to the floor.

Provide support by holding the client's arm

Answer and Explanation

The Correct Answer is C

Choice A rationale: Leaning the client toward the wall may not provide sufficient support and could lead to a fall.
Choice B rationale: Assuming a narrow base of support does not provide adequate stability when a client is falling.
Choice C rationale: Lowering the client to the floor is a safety measure to prevent injury during a fall. It reduces the distance of the fall and minimizes the risk of injury.
Choice D rationale: Providing support by holding the client's arm may not be sufficient to prevent a fall. Lowering the client to the floor is a safer option.

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Correct Answer is B

Explanation

Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.

A. Stop the treatment if the client's skin becomes red. B. Leave the pad in place for at least 40 min. C. Use safety pins to keep the pad in place. D. Set the pad's temperature to 42.2° C (108° F).

Correct Answer is A

Explanation

Choice A rationale: If the client's skin becomes red, the heat application should be stopped to prevent burns or skin damage.
Choice B rationale: Heat applications are generally recommended for 20-30 minutes, not at least 40 minutes, to avoid skin damage.
Choice C rationale: Safety pins should not be used to keep the heating pad in place, as they can damage the pad or cause injury to the client.
Choice D rationale: The temperature of the heating pad should be set to a comfortable and safe level, typically below 42.2° C (108° F).

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A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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