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: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.

A. A physician’s order is needed B. Use a lubricated index finger to break up some of the mass and remove it C. Sterile gloves should be used for the procedure D. The mass should be removed as a whole E. The patient should be in the side lying position.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale: A physician's order is typically required for a digital removal of a fecal impaction.
Choice B rationale: Using a lubricated index finger to break up some of the mass and remove it is a correct step in the procedure.
Choice C rationale: Sterile gloves are not required for a digital removal of a fecal impaction. Clean gloves are generally sufficient.
Choice D rationale: The mass may need to be broken up into smaller pieces for removal, rather than being removed as a whole.
Choice E rationale: The patient is usually positioned in a side-lying position for comfort and accessibility during the procedure.

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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

A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

Correct Answer is A

Explanation

A nurse is preparing to complete a digital removal of a fecal impaction. What statement indicates the nurse has an appropriate understanding of this procedure? (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

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