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. Ask the chaplain to discuss death issues with the client: While spiritual support may be helpful, this does not address the client’s expressed conflict about continuing treatment to satisfy his family’s wishes.

B. Notify the family that treatments have been discontinued: The nurse cannot make the decision to discontinue treatments without the client’s and healthcare provider’s input. This would be outside the nurse’s scope of authority.

C. Request a consultation with the hospital social worker: Although a social worker can help with emotional support and end-of-life planning, the immediate concern is facilitating open communication between the client, family, and healthcare team about the client’s wishes.

D. Arrange a meeting with the family, healthcare provider, and client: This action supports the client’s autonomy and ensures his wishes are heard. It also promotes collaborative decision-making about continuing or stopping treatment, aligning care with the client’s goals and values.

A. Use a picture of clock to indicate the dose times. B. Mark the dose on the syringe using color coded tape. C. Instruct them to add the medication to formula or juice. D. Place a color code on the medication containers. E. Schedule medication times with feeding times.

Correct Answer is ["A","B","D","E"]

Explanation

A. Use a picture of a clock to indicate the dose times: Visual aids help parents with limited literacy or cognitive challenges understand when to give medications, improving adherence and safety.

B. Mark the dose on the syringe using color-coded tape: Color-coded markings provide a clear, simple guide for accurate dosing, reducing the risk of errors.

C. Instruct them to add the medication to formula or juice: Mixing medications with food or drink can alter absorption, interfere with effectiveness, or result in incomplete ingestion. This practice is generally discouraged unless specifically approved by the healthcare provider.

D. Place a color code on the medication containers: Color-coded containers help parents quickly identify the correct medication and dose, supporting safe administration.

E. Schedule medication times with feeding times: Aligning medication administration with regular daily routines such as feeding helps parents remember doses and promotes adherence to the prescribed schedule.

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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

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Explanation

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