A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
dropdown
followed by
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Rationale for Correct Answers:

Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Impaired hearing: Impaired hearing can increase the risk of injury by reducing the client’s ability to hear alarms or warnings. However, it is considered a sensory impairment rather than a lifestyle choice.

B. Reduced health literacy: Low health literacy can contribute to poor understanding of safety instructions and adherence to precautions, increasing injury risk. Nonetheless, it relates more to knowledge deficits than lifestyle behaviors.

C. Lower extremity weakness: Weakness in the legs increases fall risk due to impaired mobility and balance. This is a physical or functional risk factor rather than a lifestyle risk.

D. Texting while driving: Texting while driving is a high-risk lifestyle behavior directly associated with increased injury and accident rates. It involves voluntary behavior that compromises safety and is a preventable cause of injury.

A. An assistive personnel raises all four side rails of a client's bed before leaving the room. B. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks. C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds. D. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site.

Correct Answer is A

Explanation

A. An assistive personnel raises all four side rails of a client's bed before leaving the room: Raising all four side rails can be considered a form of restraint and poses a safety risk, especially if the client attempts to climb over them. It can increase the risk of falls and injury, particularly in confused or restless clients.

B. An assistive personnel places a weight-sensitive sensor mat on the mattress beneath a client's buttocks: This is not a safety hazard; it's a fall prevention measure. These sensor mats are designed to alert staff when a client attempts to get up, helping prevent falls in at-risk individuals.

C. A client who has bilateral wrist restraints has a capillary refill of less than 2 seconds:
A capillary refill of less than 2 seconds is within normal limits and indicates that circulation to the hands is intact. This suggests that the restraints are not too tight and do not currently pose a circulatory risk to the client.

D. A client who has a transcutaneous electrical nerve stimulation unit reports a buzzing sensation at the application site: A mild buzzing or tingling sensation is an expected and normal effect of a TENS unit. It does not indicate a malfunction or a safety issue unless it becomes painful or the skin shows signs of irritation or burns.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client. Which of the following findings should the nurse identify as a lifestyle risk factor for injury?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following findings should the nurse identify as a safety hazard?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client about using guided imagery to manage chronic pain. Which of the following statements by the client indicates an understanding of this technique?

A nurse is collecting data from a client who reports feeling short of breath and notes that the client's SaO2 level is 88% while on room air. Which of the following actions should the nurse take first?

A nurse is disinfecting the room of a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use?

A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?

A nurse is caring for a client who is scheduled for a surgical procedure. Which of the following statements by the client indicates an understanding of the informed consent process?

A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day. Exhibits Complete the following sentence by using the list of options. The client is at risk for dropdown as evidenced by the client's dropdown.

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

A nurse in a provider's office is collecting data from a client. Which of the following actions should the nurse take to check the client's balance? (Select all that apply.)

A nurse is assisting in the care of a client.

Exhibits

Complete the following sentence by using the lists of options.

At 1000 the nurse enters the client's room. The first action the nurse should take is
dropdown
followed by
dropdown
.