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 A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

A. If laxatives are not effective, the client should begin to use enemas. B. Habitual laxative use is the most common cause of chronic constipation. C. A laxative that works by a different method should be used. D. Chronic constipation is nothing to be concerned about.

Correct Answer is C

Explanation

Choice A rationale: Using enemas should not be the first response to constipation. There are various types of laxatives with different mechanisms of action that can be tried before resorting to enemas.
Choice B rationale: Habitual laxative use can contribute to chronic constipation, but it is not the most common cause. It is essential to identify and address the underlying cause of constipation.
Choice C rationale: If laxatives are not effective, trying a laxative with a different mechanism of action may be more successful in relieving constipation.
Choice D rationale: Chronic constipation should be assessed and addressed, as it can lead to complications and should not be dismissed as insignificant.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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