A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?
Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs.
Keep the patient standing and call for assistance to continue to move with the help of another nurse.
Have the patient sit down on the bed and dangle her feet for a few seconds and then attempt the move again.
Continue to walk the patient to the chair and if the patient faints, lower them gently to the floor.
The Correct Answer is A
The correct answer is choice A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["725"]
Explanation
Intake = IV fluid + antibiotic
From 0700-0900 (2 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 2 hours = 200 mL
From 1000-1030 (0.5 hours), the patient received Kefzol 1 g in 25 mL of D5W over 30 minutes:
25 mL
From 1030-1530 (5 hours), the patient received 100 mL/hr of IV fluid: 100 mL/hr x 5 hours = 500 mL
Total intake from 0700-1530 = 200 mL + 25 mL + 500 mL = 725 mL. Therefore, the patient's intake from 0700 to 1530 was 725 mL.
Correct Answer is A
Explanation
The correct answer is choice A. After inserting the catheter 2-5 cm, the nurse should then inflate the balloon. It is important to confirm urine return before inflating the balloon to ensure that the catheter is in the correct position and has not entered the bladder neck or prostate. Inflating the balloon before confirming urine return can cause trauma and increase the risk of infection. Option B is incorrect because inflating the balloon too early can cause discomfort, trauma and increase the risk of infection. Option C is incorrect because advancing the catheter too far can cause injury to the bladder or ureters. Option D is incorrect because pulling back the catheter after meeting resistance can also cause trauma to the urethra.
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