The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)
Bends from the waist to pick trash off the floor.
Widens stance while working near the sink.
Locks knees while preparing food on the counter.
Brings a heavy can close to body before lifting.
Leans forward to pull a pan from a high shelf
Correct Answer : B,D
A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to
the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Correct Answer is B
Explanation
A) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.
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