A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Assess the patient.

File a safety event report

Place the patient on fall precautions.

Get the patient back to bed.

Answer and Explanation

The Correct Answer is A

A. Assess the patient: The priority action is to assess the patient for injuries before taking any further steps.

B. File a safety event report: This is important but should be done after assessing and ensuring the patient’s safety.

C. Place the patient on fall precautions: While necessary, this is a secondary intervention after assessment and ensuring immediate safety.

D. Get the patient back to bed: Moving the patient before assessing for injuries could worsen potential fractures or other injuries.

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Correct Answer is C

Explanation

A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.

B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.

C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.

D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.

A. Applies non skid socks before getting the patient out of bed. B. Activates the chair alarm when the patient is sitting in the chair. C. Ensures that the bed is in the lowest position prior to leaving the room. D. Places the patient on bedrest.

Correct Answer is D

Explanation

A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.

B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.

C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.

D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

Correct Answer is C

Explanation

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

Correct Answer is D

Explanation

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