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 D

Explanation

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

A. Provide the client with a bedpan to reduce ambulating to the restroom B. Administer pain medications sparingly in order to minimize any cognitive side effects C. Place the client in a shared room with a client who is stable and oriented D. Orient the client to the room and environment upon admission

Correct Answer is D

Explanation

A. Provide the client with a bedpan to reduce ambulating to the restroom: While limiting unnecessary movement can help prevent falls, using a bedpan is not the best intervention unless the patient is completely immobile.

B. Administer pain medications sparingly in order to minimize any cognitive side effects: Undertreating pain can lead to restlessness and unsteady movement, which may increase fall risk rather than prevent it.

C. Place the client in a shared room with a client who is stable and oriented: Roommate selection does not directly reduce fall risk. A shared room does not guarantee supervision or fall prevention.

D. Orient the client to the room and environment upon admission: Older adults may be disoriented in a new environment, increasing fall risk. Orienting them to the room (call light, bathroom location, bed height) helps them move safely.

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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

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