A nurse is assisting with the admission of an older adult client who has impaired mobility and is at risk for falls. Which of the following actions should the nurse plan to perform first?
Check the client's ability to use the call light.
Document the client's risk in the medical record.
Request a referral for physical therapy
Place a gait belt in the client's room.
The Correct Answer is A
The first action the nurse should plan to perform is to check the client's ability to use the call light. This is essential to ensure that the client can easily communicate with the healthcare team if they need assistance or experience a fall risk situation. By confirming the client's ability to use the call light, the nurse can address any potential communication barriers and ensure that the client has a means to request help promptly.
Explanation for the other options:
b) Document the client's risk in the medical record: While documenting the client's risk in the medical record is important, it is not the first action to be taken. Ensuring the client's immediate safety and ability to request assistance is the priority.
c) Request a referral for physical therapy: Referring the client for physical therapy may be a necessary step to address their impaired mobility and reduce fall risk, but it is not the first action to be performed. Assessing their ability to use the call light takes precedence in order to address immediate safety concerns.
d) Place a gait belt in the client's room: Providing a gait belt is a measure to assist with mobility and falls prevention. However, it should not be the first action. Checking the client's ability to use the call light is more critical to ensure their immediate safety and ability to request help.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The client has state-sponsored health insurance: While information about the client's health insurance coverage is important for billing and financial purposes, it may not be directly relevant to the discussion in an interprofessional team meeting unless it specifically impacts the client's access to healthcare resources or affects decision-making regarding their care plan.
The reason for including this information is that difficulty ambulating can impact the client's overall mobility and functional status. It can have implications for their ability to perform activities of daily living, increase the risk of falls, and require additional interventions or resources. By sharing this information with the interprofessional team, appropriate strategies and interventions can be discussed and implemented to address the client's mobility issues.
The client's next dressing change is scheduled in 4 hours: The timing of the client's dressing change may be important for nursing documentation and scheduling purposes. However, it may not be a significant focus of discussion in an interprofessional team meeting unless there are specific concerns or issues related to the dressing change that require collaboration and coordination among the healthcare team.
The client's vital signs are checked every 8 hours: The frequency of vital sign checks is an important aspect of nursing care and monitoring. However, unless there are specific concerns or deviations from normal vital signs that need to be discussed, it may not be the primary information to include in an interprofessional team meeting. The focus of the meeting is typically on broader aspects of the client's condition, care plan, and multidisciplinary interventions.
Correct Answer is D
Explanation
When a client with active pulmonary tuberculosis (TB) receives appropriate treatment and their sputum cultures consistently show negative results for Mycobacterium tuberculosis, it indicates that the client is no longer contagious. Negative sputum cultures indicate that the infectious bacteria are no longer present or viable in the respiratory secretions, reducing the risk of transmitting the disease to others.
"You will need an annual TB skin test to see if the infection has returned": While it is important for individuals with a history of TB to undergo periodic screening, such as an annual TB skin test or interferon-gamma release assay (IGRA), to detect latent TB infection or potential reactivation, this response is not specifically related to a client with active pulmonary TB.
"You will take medication to treat your illness for the rest of your life": This response is incorrect because active pulmonary TB is typically treated with a combination of antimicrobial medications for a specific duration, usually ranging from 6 to 9 months. It is not a lifelong treatment.
However, individuals with latent TB infection may require longer-term treatment to prevent the development of active TB disease.
"You can expect the medications to turn your urine a blue-green color": This response is incorrect as medications used to treat TB do not typically cause urine discoloration. Medications such as rifampin can cause various side effects, including orange discoloration of bodily fluids like urine, tears, or sweat, but a blue-green color is not associated with TB medications.
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