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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Glucose and calcium levels: While hyperglycemia can occur secondary to stress, glucose and calcium are not the primary indicators of severity in a thyrotoxic crisis.

B. Blood and urine cultures: Cultures are important if infection is suspected as a trigger, but they do not reflect the systemic impact of a thyrotoxic crisis itself.

C. Renal and liver function tests: Thyrotoxic crisis can lead to multi-organ stress, including hepatic dysfunction and impaired renal perfusion. Monitoring liver enzymes and renal function helps detect complications early and guide interventions.

D. Electrolytes and hemoglobin: Electrolytes may fluctuate and anemia may exist, but they are not the most critical values to monitor during the acute phase of a thyrotoxic crisis compared with organ function indicators.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing. B. Peripheral pulses present with full range of motion of both legs. C. Declining to take ice chips despite reporting of dry mouth. D. History of vomiting at home for 3 days prior to surgery.

Correct Answer is D

Explanation

A. Soft abdomen, absent bowel sounds, no bleeding on dressing: This provides relevant post-operative assessment information, but it reflects the current status rather than additional history affecting immediate care priorities.

B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.

C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.

D. History of vomiting at home for 3 days prior to surgery: This is significant additional information because prolonged preoperative vomiting can lead to fluid and electrolyte imbalances, increasing the risk for complications post-operatively. The receiving nurse needs to be aware to guide monitoring and interventions.

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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?

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Naxlex Comprehensive Predictor Exams

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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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?

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