A nurse is caring for a patient who is postoperative following foot surgery and is not to bear weight on the operative foot. The nurse enters the room to discover the patient hopped on one foot to the bathroom, using an IV pole for support. Which of the following actions should the nurse take?
Keep the bathroom door open to ensure the patient is okay.
Walk the patient back to bed immediately and get the patient a bedpan.
Warn the patient they might have to be restrained if they get up without assistance.
Tell the patient to remain in the bathroom after toileting and obtain a wheelchair.
The Correct Answer is D
Choice A reason: Keeping the bathroom door open does not address the safety risk of the patient bearing weight on the operative foot.
Choice B reason: While it is important to assist the patient back to bed, providing a bedpan does not address the immediate safety concern.
Choice C reason: Warning the patient about restraints is not appropriate without first educating the patient about the importance of not bearing weight and the potential risks.
Choice D reason: Telling the patient to remain in the bathroom until a wheelchair can be obtained ensures the patient's safety and prevents further weight-bearing on the operative foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hyperventilation is a compensatory mechanism in metabolic acidosis where the body tries to decrease carbon dioxide levels to balance the acidity.
Choice B reason: Cold, clammy skin is not a typical manifestation of metabolic acidosis; it may be associated with shock or hypoglycemia.
Choice C reason: Increased blood pressure is not directly related to metabolic acidosis. It can be influenced by various factors, including stress or other underlying conditions.
Choice D reason: Bradycardia, or a slow heart rate, is not a common manifestation of metabolic acidosis. Tachycardia, or a fast heart rate, might be observed instead.
Correct Answer is A
Explanation
Choice A reason: Hyperventilation is a common response to respiratory alkalosis as the body tries to compensate for the high pH by exhaling more carbon dioxide.
Choice B reason: Dyspnea, or difficulty breathing, may be present but is not as specific as hyperventilation for respiratory alkalosis.
Choice C reason: Abdominal pain is not typically associated with respiratory alkalosis.
Choice D reason: Dizziness can be a symptom of respiratory alkalosis due to changes in blood chemistry, but it is less specific than hyperventilation.
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