A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Drive the client to the nearest emergency department.

Obtain the telephone number of the client's provider.

Find a location for the client to sit.

Call emergency services.

Answer and Explanation

The Correct Answer is D

A. Driving the client to the emergency department is not appropriate when the client is experiencing symptoms of a potential stroke; immediate medical assessment is needed.
B. Obtaining the telephone number of the client's provider does not address the immediate need for emergency medical care.
C. Finding a location for the client to sit does not address the urgency of the situation; prompt medical attention is crucial.
D. Calling emergency services is the correct action to ensure the woman receives timely medical care for stroke symptoms.

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Correct Answer is B

Explanation

A. Positioning the wrapped package with the outer flap away helps maintain sterility when opening.
B. Holding gauze packages 15 cm (6 in) above the sterile field is incorrect; sterile items should be held at least 15 cm (6 in) above the sterile field to maintain sterility.
C. Holding a bottle of solution with the label away from the palm helps prevent contamination.
D. Wearing sterile gloves when handling sterile items on the sterile field helps maintain sterility.

A. A client with diabetes mellitus who has a leg ulcer B. An adolescent client who has a leg fracture and has been using crutches for the past 2 days C. An older adult client who is confused and has urinary frequency D. A client who is 1 day postoperative and has a nursing assistant helping him out of bed

Correct Answer is C

Explanation

A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.

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A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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