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 D
Explanation
The nurse should expect the provider to discontinue phenelzine 2 weeks before starting fluoxetine treatment. Phenelzine is a monoamine oxidase inhibitor (MAOI) and should not be taken with fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI). Taking these two medications together can cause a dangerous drug interaction known as serotonin syndrome.
a) Levothyroxine is a thyroid hormone replacement medication and does not interact with fluoxetine.
b) Acetaminophen is a pain reliever and does not interact with fluoxetine.
c) Simvastatin is a cholesterol- lowering medication and does not interact with fluoxetine.
Correct Answer is D
Explanation
ESR is a laboratory test that measures the rate at which red blood cells settle in a vertical tube of blood over a specific period of time. An elevated ESR is a nonspecific indicator of inflammation in the body, including infections. In the presence of an infection, the body releases certain substances that can increase the rate at which red blood cells settle, leading to an elevated ESR.
Decreased platelet count is not typically associated with infection. Low platelet count, known as thrombocytopenia, can be caused by various factors such as certain medications, autoimmune disorders, or bone marrow disorders. Infection may cause other changes in blood counts, but decreased platelets are not a direct indicator of infection.
Decreased hemoglobin levels, known as anemia, can be caused by various factors such as nutritional deficiencies, chronic diseases, or blood loss. While some infections can lead to anemia indirectly, decreased hemoglobin is not a specific indicator of infection.
Increased iron levels, known as hyperferritinemia, can occur in various conditions, including infections, but it is not a direct indicator of infection. It is important to assess the overall clinical picture and other laboratory findings to determine the cause of increased iron levels.
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