A nurse responds to a call light and finds a patient lying on the bathroom floor. What should the nurse do first?
Check the patient for injuries.
Move hazardous objects away from the patient.
Notify the provider.
Ask the patient to describe how they felt prior to the fall.
The Correct Answer is A
Choice A rationale
The first action the nurse should take when finding a patient on the floor is to check the patient for injuries. This is important to determine the extent of any potential harm and to guide subsequent actions.
Choice B rationale
Moving hazardous objects away from the patient is important, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.
Choice C rationale
Notifying the provider is an important step when a patient falls, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.
Choice D rationale
Asking the patient to describe how they felt prior to the fall is part of the assessment after a fall, but it is not the first action the nurse should take. The nurse should first assess the patient for injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.
Choice B rationale
Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.
Choice C rationale
Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.
Choice D rationale
Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.
Correct Answer is C
Explanation
Choice A rationale
A patient being in a wheelchair with the wheels locked does not necessarily indicate elder abuse. It could simply mean that the patient has mobility issues and the wheelchair is a means of transportation for them. The wheels being locked could be a safety measure to prevent the wheelchair from moving unexpectedly.
Choice B rationale
The patient reporting receiving a full bath twice each week does not indicate elder abuse. In fact, it shows that the patient’s hygiene needs are being met regularly. Regular bathing is part of good personal hygiene and is important for overall health.
Choice C rationale
The caregiver insisting on staying in the room during the nurse’s assessment could be a potential sign of elder abuse. This could indicate that the caregiver is controlling or overbearing, and may be trying to monitor or control the patient’s interactions with others. It could also suggest that the caregiver is trying to hide something or prevent the patient from speaking freely.
Choice D rationale
The caregiver being the patient’s financial power of attorney does not necessarily indicate elder abuse. A financial power of attorney is a legal document that gives someone the authority to handle financial transactions on behalf of another person. It is often used when a person is unable to manage their own financial affairs due to illness or incapacity.
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