A nurse is preparing to conduct a fall risk screening on a client.
Which of the following variables will the nurse use to evaluate the client? (Select all that apply.)
Fall history.
Medical diagnosis.
Use of assistive devices.
Mental status.
Do-not-resuscitate status.
Correct Answer : A
Choice A rationale:
Maintaining the patency of the client's airway is the priority action. During a seizure, the client may lose consciousness and have difficulty breathing. Ensuring a clear airway is essential to prevent hypoxia and maintain oxygenation. This can be achieved by positioning the client on her side and removing any obstructions from her mouth to allow for adequate airflow.
Choice B rationale:
Identifying the poison the client ingested is important for providing appropriate medical treatment, but it is not the priority action in this scenario. Airway management takes precedence because it addresses the immediate threat to the client's life.
Choice C rationale:
Measuring the client's blood pressure is a necessary assessment, but it is not the priority during an active seizure. Airway management and seizure control are the immediate concerns. Once the seizure is controlled and the airway is secured, other assessments, including blood pressure measurement, can be performed.
Choice D rationale:
Positioning the client on her side is a correct action, but it should be done after ensuring the patency of the airway. Placing the client on her side helps prevent aspiration in case of vomiting during or after the seizure. However, it is not the priority over ensuring the client can breathe properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Diazepam is prescribed in a 10 mg dose, and the concentration of diazepam in the injection is 5 mg per mL. By dividing the prescribed dose (10 mg) by the concentration of the drug in the injection (5 mg/mL), the result is 2 mL. This is the correct administration dose.
Correct Answer is A
Explanation
Choice A rationale:
Diastolic pressure represents the pressure in the arteries when the heart is at rest between contractions. It specifically measures the force of blood against the arterial walls when both the atria and ventricles are relaxed, allowing the heart to fill with blood. Diastolic pressure is the bottom number in a blood pressure reading (e.g., 120/80 mmHg), indicating the pressure in the arteries during the heart's resting phase. Elevated diastolic pressure is an important indicator of increased risk for cardiovascular diseases, such as hypertension.
Choice B rationale:
This statement describes systolic blood pressure, which measures the pressure in the arteries when the heart's ventricles contract and pump blood into the circulation. Systolic pressure is the top number in a blood pressure reading (e.g., 120/80 mmHg) and represents the highest pressure reached in the arteries during a cardiac cycle.
Choice C rationale:
This description is not accurate for either diastolic or systolic pressure. Both atria and ventricles do not contract simultaneously; they follow a specific sequence to ensure effective pumping of blood through the heart.
Choice D rationale:
This statement is incorrect as it does not align with the definitions of diastolic or systolic blood pressure. Diastolic pressure specifically measures the pressure in the arteries during the heart's resting phase, not when the ventricles relax. .
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