Difficulty: Medium
Average Score: 86%
Simulated
Passage / Scenario
Flow sheets1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2┬░ F (36.8┬░ C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The client continues to have stable neurologic assessments. The nurse provides interventions to promote client safety while in the hospital. Of the interventions below, explain if it promotes clients safety or not, or does both.
Correct answer
B,C,D,F
Rationale
Swallow study, call button, bed alarm, and instructing to call promote safety by preventing aspiration, falls, and ensuring assistance. Elevator proximity and unreachable belongings do not.