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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Along either upper gum line, adjacent to an incisor:Placing the thermometer along the upper gum line near the incisors would not accurately reflect the body's core temperature. The posterior sublingual pocket provides a more reliable reading.

B. Deep in the posterior sublingual pocket:The sublingual pocket, located under the tongue toward the back, is the best place for measuring oral temperature. This area has a good blood supply from the carotid arteries, making it ideal for an accurate temperature reading.

C. In the inferior buccal space on either side of the tongue:The buccal space is not ideal for temperature measurement, as it does not have the same consistent blood supply and is more prone to error due to airflow from breathing.

D. Superior to the tongue with the tip touching the hard palate:Placing the thermometer on top of the tongue against the hard palate would result in an inaccurate reading because this location does not effectively reflect the body's core temperature.

A. Use a whirlpool bath. B. Use water and mild soap. C. Use alcohol-based sanitizer. D. Use chlorhexidine or HCG.

Correct Answer is B

Explanation

The correct answer is choice B, Use water and mild soap.

When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

Correct Answer is B

Explanation

The nurse is teaching a patient with a new ostomy about skin care to preserve tissue integrity. What teaching will the nurse provide about cleansing the ostomy area?

Correct Answer is B

Explanation

Which statement by a nurse would be the most therapeutic response to a patient who cannot decide if they want to receive recommended chemotherapy treatment?

A nurse asks a client the current level of pain using a scale of 0 to 10 after administering pain medications 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.

Ancient has developed dysphagia secondary to a cerebrovascular accident. The doctor has ordered pureed diet with nectar thick liquids. Which of the following would be appropriate for this client?

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

A nurse is caring for an alert and oriented client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family on behalf of the client?