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 B

Explanation

A. A patient who is lying on wrinkled sheets: Wrinkled sheets can cause pressure injuries, but they do not directly lead to shearing.

B. A patient who is pulled up in the bed by the nurse: Shearing occurs when the skin remains in place while underlying tissues move, often when a patient is dragged up in bed instead of lifted. This can damage skin layers and underlying tissues.

C. A patient who is frequently incontinent: Incontinence increases the risk of moisture-associated skin damage and pressure injuries but is not directly related to shearing.

D. A patient who is noted to have slough tissue: The presence of slough (dead tissue in a wound) indicates existing tissue damage but does not suggest an increased risk of shearing.

A. It is painful to sit on a bedpan. B. The position encourages the Valsalva maneuver. C. The position does not facilitate downward pressure. D. The cause is unknown and requires further study.

Correct Answer is C

Explanation

A. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

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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

Which of the following patients are at highest risk for developing a skin injury caused by shearing?

Correct Answer is B

Explanation

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

Correct Answer is C

Explanation

The nurse has received a report for the following patients. Which patient should be seen first?

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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?

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The nurse is assessing the patient's output for the shift. What finding is most concerning?

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You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?