A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Demonstrate to the client how to use the signaling device.

Explain the facility's meal schedule

Demonstrate to the client how to use the television.

Explain the medication administration schedule.

Answer and Explanation

The Correct Answer is A

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

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Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

A. Use humor to decrease tension. B. Speak in short sentences. C. Speak in third person. D. Talk directly to the interpreter.

Correct Answer is B

Explanation

A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.

B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.

C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.

D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.

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A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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