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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.
Correct Answer is D
Explanation
Choice A rationale: The stool test for occult blood is not primarily designed to detect bacteria.
Choice B rationale: Parasites are not typically detected through a stool test for occult blood.
Choice C rationale: Steatorrhea refers to the presence of excess fat in the stool and is not the primary focus of a stool test for occult blood.
Choice D rationale: The purpose of the stool test for occult blood is to check for the presence of blood in the stool, which may not be visible to the naked eye. This can be an indicator of gastrointestinal bleeding.
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