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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.

Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.

Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.

A. Shrimp salad B. Roasted salmon C. Pulled-pork sandwich D. Clam chowder

Correct Answer is B

Explanation

Kosher dietary laws, as observed in Judaism, have specific dietary restrictions. One of the primary restrictions is the prohibition of consuming shellfish and pork. Shrimp and clam chowder, which are made from shellfish, and the pulled-pork sandwich, which contains pork, are not suitable options for a kosher diet.

Roasted salmon, on the other hand, is an appropriate choice. Fish that have both fins and scales, such as salmon, are considered kosher and can be included in a kosher diet.

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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?

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