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 A
Explanation
The correct answer is choice A, carbohydrates, protein, and lipids. These three nutrients are referred to as macronutrients and are the main sources of energy for the body. Carbohydrates are the body's preferred source of energy, while protein and lipids can also be used for energy when carbohydrates are not available. The other three choices, vitamins, minerals, and water, are essential for various body functions, but they do not provide energy.
Correct Answer is D
Explanation
The correct answer is choice D, Jell-O, broth, apple juice. A clear liquid diet consists of fluids and foods that are clear and liquid at room temperature. These foods are easy to digest and leave no residue in the gastrointestinal tract. Examples include water, clear fruit juices, clear broths, tea, coffee without cream, and Jell-O.
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