NCLEX-PN

Category - Basic Care

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The nurse is assigned to care for a client who lost consciousness following a fall. The following nursing actions are appropriate for the client except:

Using the side rails at all times
Assisting the client in Trendelenburg position
Preparing a tracheostomy set at bedside
Changing of position every 2 hours

Explanation

Answer: B - A client who loses consciousness is in a state of decreased cerebral functioning with unresponsiveness to motor and sensory functions. The nurse should avoid placing the client in Trendelenburg position, as it can further increase the client’s intracranial pressure. The other options are appropriate.

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