A nurse assesses a patient with restraints. The nurse should:

Loosen the restraints and assess the patient’s skin.

Document the findings in the patient’s chart.

Continue to monitor the patient without making any changes.

Apply ice packs to reduce swelling.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale

A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.

A. Evaluation. B. Assessment. C. Planning. D. Implementation.

Correct Answer is B

Explanation

Choice A rationale
Evaluation is the phase of the nursing process where the nurse assesses the effectiveness of the interventions and determines whether the patient’s goals have been met. Checking blood sugar before administering insulin is not part of the evaluation phase.
Choice B rationale
Assessment is the phase of the nursing process where the nurse gathers information about the patient’s condition. Checking the client’s blood sugar before administering insulin is an assessment activity, as it involves collecting data to determine the patient’s current blood glucose level.
Choice C rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data. Checking blood sugar is not part of the planning phase; it is an assessment activity.
Choice D rationale
Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the plan of care. While administering insulin is part of the implementation phase, checking blood sugar is an assessment activity that occurs before the implementation of the intervention.

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A nurse assesses a patient with restraints. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is checking the client’s blood sugar before administering insulin to a diabetic client. Which part of the nursing process is being fulfilled?

Correct Answer is B

Explanation

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