A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Review the patient's activity orders.

Medicate the patient to alleviate discomfort while ambulating.

Ask for at least two other assistive personnel to come to the room.

Offer the patient a walker.

Answer and Explanation

The Correct Answer is A

A. Before assisting a patient, especially one with mobility concerns, the nurse must verify provider orders to determine any restrictions or special considerations.

B. Administering pain medication before knowing activity restrictions could lead to falls or complications.

C. While assistance may be needed, the first priority is to check the patient's activity orders to determine the safest way to proceed.

D. Providing a walker might help, but the nurse must first confirm whether assistive devices are appropriate for the patient.

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Correct Answer is B

Explanation

A. While long-term immobility increases the risk of skin breakdown, this is not the primary concern in this scenario.

B. The patient exhibits fatigue, increased heart rate, and orthostatic hypotension, indicating reduced ability to tolerate physical activity, making Activity Intolerance the most appropriate diagnosis.

C. While ICU patients may be at risk for infection, there is no evidence of active infection in this scenario.

D. Orthostatic hypotension can be linked to dehydration, but the case does not provide enough information to confirm a fluid volume deficit.

A. Direct the nursing assistive personnel to give the acetaminophen. B. Perform a pain assessment only after administering the acetaminophen. C. Notify the health care provider to obtain a verbal order. D. Administer the acetaminophen.

Correct Answer is D

Explanation

A. Direct the nursing assistive personnel to give the acetaminophen. This is incorrect because administering medication is outside the scope of practice for nursing assistive personnel. Only licensed nurses are authorized to administer medications.

B. Perform a pain assessment only after administering the acetaminophen. This is incorrect because a pain assessment should be conducted before administering a PRN medication to determine the severity and characteristics of the pain.

C. Notify the health care provider to obtain a verbal order. This is incorrect because the medication is already included in the standing orders. There is no need to obtain a verbal order when the medication has already been prescribed with specific administration parameters.

D. Administer the acetaminophen. This is correct because the nurse has assessed the patient’s need for pain relief, confirmed that the patient has not received the medication in the past four hours, and verified that it falls within the provider’s orders. Since all criteria are met, the nurse should proceed with administering the medication as prescribed.

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A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Correct Answer is D

Explanation

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