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 B
Explanation
Choice A rationale:
Airborne transmission typically involves smaller particles that can remain suspended in the air for longer periods. Sneezing, in this case, usually produces smaller droplets that can travel farther distances and potentially infect individuals beyond a few feet away.
Choice B rationale:
Direct contact transmission occurs when there is physical contact between an infected person and a susceptible individual. In this scenario, the infected drainage from the client's wound directly touches the nurse's cut, leading to infection. This type of transmission is characterized by the transfer of microorganisms through physical touch or contact with the skin.
Choice C rationale:
Droplet contact transmission involves larger respiratory droplets that are expelled when a person coughs, sneezes, or talks. These droplets typically do not travel far and can only infect people who are in close proximity. In this case, the scenario describes a client coughing on their hand and another person becoming infected by touching the contaminated door handle. This aligns with direct contact transmission rather than droplet contact transmission.
Choice D rationale:
Indirect contact transmission refers to the transfer of an infectious agent from a contaminated surface or object to a susceptible person. However, the scenario provided does not involve the nurse coming into contact with a contaminated surface but rather with the infected drainage directly. Therefore, this scenario is best categorized under direct contact transmission.
Correct Answer is B
Explanation
Choice A rationale:
A combining vowel is a vowel (usually "o") that connects a word root to a suffix or another root. It aids in the pronunciation and flow of the word. For example, in the word "gastroenteritis," "o" is the combining vowel that connects the word root "gastr-" (stomach) to the suffix "-itis" (inflammation) Combining vowels do not provide the general meaning of the word.
Choice B rationale:
The word root provides the fundamental meaning of the word. It is the core of the medical term and gives the essential meaning. For example, in the word "cardiology," the word root "cardio-" refers to the heart. Understanding word roots is crucial in comprehending medical terminology.
Choice C rationale:
A suffix is an affix added at the end of a word to form a derivative, indicating a characteristic of a person or thing. For instance, in the word "dermatologist," the suffix "-ologist" indicates a person who studies or practices a particular kind of knowledge, in this case, dermatology (the study of the skin)
Choice D rationale:
A prefix is an affix added to the beginning of a word to modify its meaning. For example, in the term "preoperative," the prefix "pre-" means before, and it modifies the root word "operative," indicating something that occurs before an operation. Prefixes provide additional information about the word's context but do not give the general meaning of the word itself.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.