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 A

Explanation

The initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for a 2-month-old infant. The DTaP vaccine is typically administered as a series of doses starting in infancy to provide protection against diphtheria, tetanus, and pertussis (whooping cough).

The recommended schedule for the DTaP vaccine includes a series of doses at 2, 4, and 6 months of age, with additional booster doses given later in childhood. Therefore, the first dose of DTaP is given to infants at 2 months of age.

The other options are incorrect because:

b) A 4-month-old infant: By 4 months of age, the second dose of the DTaP vaccine should be administered, not the initial dose.

c) A 6-month-old infant: By 6 months of age, the third dose of the DTaP vaccine should be administered, not the initial dose.

d) A 15-month-old toddler: By 15 months of age, the toddler would have already received multiple doses of the DTaP vaccine as part of the recommended series. The initial dose is typically given earlier, at 2 months of age.

A. The client's most recent blood pressure reading was 110/60 mm Hg. B. The client's morning laboratory results included a potassium level of 4.9 mg/dL. C. The client has +2 pitting edema in the lower extremities. D. The client's partner assisted them with their meal tray.

Correct Answer is D

Explanation

The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.

A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.

The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following clients?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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