A nurse is caring for a client who ingested a poison and is now having seizures.
Which of the following is the priority action the nurse should take?
Maintain the patency of the client's airway.
Identify the poison the client ingested.
Measure the client's blood pressure.
Position the client on her side.
The Correct Answer is A
Choice A rationale:
"I will keep my walker at the end of my bed." This statement indicates that the client understands the importance of having the walker within reach. Placing the walker at the end of the bed ensures that the client can use it immediately upon getting up, providing support and stability, thus reducing the risk of falls.
Choice B rationale:
"I will keep the fluorescent ceiling light on in my room at night." While having adequate lighting is important, using a fluorescent ceiling light throughout the night might disrupt the client's sleep. Additionally, a nightlight or a bedside lamp with a low-wattage bulb can provide sufficient illumination without disturbing sleep.
Choice C rationale:
"I will place an area rug at the entry of my bathroom." This statement indicates a lack of understanding. Area rugs can be tripping hazards, especially in areas prone to moisture like bathrooms. It is advisable to remove rugs and ensure non-slip flooring to prevent slips and falls.
Choice D rationale:
"I will place a bath seat in my shower to use when I bathe." While using a bath seat is a good safety measure, it does not address the client's risk of falling outside the shower area. Installing grab bars and non-slip mats in the bathroom, along with removing potential hazards, would be more comprehensive in ensuring the client's safety. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Instruct the clients to use the call light.
Choice A rationale:
Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.
Choice B rationale:
Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.
Choice C rationale:
Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.
Choice D rationale:
Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.
Correct Answer is A
Explanation
Choice A rationale:
Proper hand-washing technique involves washing hands for at least 20 seconds. This duration ensures thorough cleansing and removal of germs, dirt, and contaminants from the hands. Washing for a shorter time, such as 10 seconds (Choice B), may not effectively eliminate all harmful microorganisms, increasing the risk of infections and transmission of diseases.
Choice B rationale:
Washing hands for only 10 seconds is insufficient to achieve the necessary level of cleanliness. It is essential to follow recommended guidelines to prevent the spread of infections in healthcare settings and other environments where hygiene is crucial.
Choice C rationale:
Washing hands for 45 seconds (Choice C) is longer than the recommended duration and might not be practical, especially in busy healthcare settings. While thorough hand hygiene is essential, excessively long washing times could lead to reduced compliance among healthcare workers, potentially compromising patient safety.
Choice D rationale:
Proper hand-washing technique involves scrubbing hands for at least 20 seconds, making Choice D incorrect. Following the recommended guidelines is crucial to maintaining a safe and hygienic healthcare environment.
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