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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

A. Straight catheter. B. Indwelling urethral catheter C. Suprapubic catheter D. Intermittent urethral catheter

Correct Answer is C

Explanation

A. Straight catheter: A straight catheter is used for intermittent catheterization and cannot bypass a complete obstruction.

B. Indwelling urethral catheter: A urethral catheter may not be able to pass through a completely obstructed urethra.

C. Suprapubic catheter: A suprapubic catheter is placed directly into the bladder through the abdominal wall, bypassing the obstructed urethra, making it the best option for this client.

D. Intermittent urethral catheter: Like a straight catheter, an intermittent urethral catheter will not work if the urethra is completely obstructed.

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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

Correct Answer is C

Explanation

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?

Correct Answer is C

Explanation

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