After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?
Advise the client to grab hold of the gait belt for added support.
Support the client in an upright position until the belt is removed.
Use the gait belt to slowly guide the client back to the room.
Ease the client to the floor while holding the gait belt securely.
The Correct Answer is D
A. Advise the client to grab hold of the gait belt for added support: Once a client begins to fall, instructing them to hold the belt is ineffective and unsafe. Immediate action is needed to prevent injury.
B. Support the client in an upright position until the belt is removed: Attempting to maintain the client upright during a fall increases the risk of both the client and nurse sustaining injury.
C. Use the gait belt to slowly guide the client back to the room: Trying to walk a falling client back to the room is unsafe and does not prevent injury.
D. Ease the client to the floor while holding the gait belt securely: Safely lowering the client to the floor while maintaining control of the gait belt minimizes the risk of injury to both the client and the nurse, following proper fall safety procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Remind the client to keep his appointments to have his cholesterol level checked: Ezetimibe works by reducing absorption of cholesterol in the intestines, which lowers serum lipid levels. The most direct way to evaluate effectiveness is through laboratory testing of cholesterol levels at scheduled follow-up appointments.
B. Assess the elasticity of the client's skin at the next scheduled clinic appointment: Skin elasticity is not affected by cholesterol-lowering therapy and does not provide meaningful information about the effectiveness of ezetimibe.
C. Teach the client to weigh himself weekly and keep a log of the measurements: Weight monitoring is more relevant for managing conditions like heart failure or obesity. Ezetimibe’s primary effect is on lipid levels, not weight change.
D. Encourage the client to keep a diary of his food intake until his next visit to the clinic: While dietary tracking supports lifestyle management, it does not directly measure the pharmacologic effectiveness of ezetimibe. Laboratory results remain the standard for evaluation.
Correct Answer is D
Explanation
A. Iodine: An iodine allergy is more relevant for clients receiving contrast media or iodine-based antiseptics, not dorzolamide. Dorzolamide is a carbonic anhydrase inhibitor, and its risk profile is not associated with iodine sensitivity.
B. Latex: Latex allergy is an important consideration in nursing care, particularly regarding equipment and supply use. However, dorzolamide as an ophthalmic preparation does not contain latex, so this allergy does not directly influence the safety of administering the drug.
C. Penicillin: Penicillin allergy is significant for antibiotics, but dorzolamide is not a beta-lactam or related medication. There is no cross-reactivity between penicillin and carbonic anhydrase inhibitors, making this allergy less concerning for this prescription.
D. Sulfonamide: Dorzolamide contains a sulfonamide component, and clients with a sulfonamide allergy are at risk for hypersensitivity reactions such as rash, conjunctivitis, or even systemic effects. Reviewing the medical record for a sulfonamide allergy is essential before administration to prevent serious complications.
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