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 B
Explanation
Choice A reason: A pH of 7.39 is near the lower end of the normal range (7.35-7.45) and would not typically indicate respiratory acidosis.
Choice B reason: A pH of 7.31 is below the normal range, indicating an acidic environment, which is consistent with respiratory acidosis.
Choice C reason: A pH of 7.48 is above the normal range, indicating a more alkaline environment, which would suggest respiratory alkalosis, not acidosis.
Choice D reason: A pH of 7.50 is also above the normal range and would indicate alkalosis rather than acidosis.
Correct Answer is B
Explanation
Choice A reason: The patient's son may be present for support, but he does not have the authority to sign the consent form unless he is a designated health care proxy and the patient is not competent.
Choice B reason: Since the patient is alert and competent, she has the right and responsibility to provide consent for her own medical procedures.
Choice C reason: A health care proxy is authorized to make decisions on behalf of the patient only if the patient is unable to do so.
Choice D reason: The consent form should be signed by the patient alone if she is competent, regardless of who accompanies her to the facility.
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