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 D

Explanation

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: While educating the client about notifying contacts is important, it does not prevent immediate transmission within the healthcare setting. It is a secondary measure.

B. Update the client and family regarding the COVID-19 vaccines that are available: Providing vaccine information is useful for long-term prevention but does not address the urgent need to reduce the risk of transmission from a potentially contagious client.

C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: Assigning the client to a designated area is important for infection control, but the immediate priority is preventing exposure to others while awaiting placement.

D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: Immediate isolation is the most critical action to prevent the spread of COVID-19. This protects other clients, visitors, and staff while testing and further management are arranged.

A. Maintain the client on bedrest. B. Administer the client's routine daily aspirin. C. Encourage a diet high in iron and ascorbic acid. D. Encourage the client to dangle the legs frequently.

Correct Answer is A

Explanation

A. Maintain the client on bedrest: The client’s symptoms are consistent with deep vein thrombosis (DVT). Bedrest with limited movement prevents dislodgment of the clot, which could otherwise travel to the lungs and cause a pulmonary embolism. This is the safest initial intervention while anticoagulation is being started.

B. Administer the client's routine daily aspirin: Aspirin has antiplatelet effects but is not the treatment of choice for acute DVT. Starting aspirin with heparin therapy is not recommended, as it increases the risk of bleeding without additional therapeutic benefit.

C. Encourage a diet high in iron and ascorbic acid: While iron and vitamin C support red blood cell production, this dietary intervention does not address the acute management of a thrombus. It may be useful in anemia prevention but is not a priority here.

D. Encourage the client to dangle the legs frequently: Dangling the legs promotes venous stasis and may worsen the clot or increase the risk of embolization. Clients with DVT should avoid activities that increase venous pooling until cleared by the healthcare provider.

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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

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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