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 lesion with uniform pigmentation is not typically a sign of skin malignancy. Most benign moles are uniform in color, including shades of tan, brown, and black.
Choice B rationale
The new appearance of petechiae, or small, pinpoint hemorrhages under the skin, is not typically associated with skin cancer. Petechiae can be a sign of a number of conditions, including certain infections, low platelet count, or certain medications.
Choice C rationale
A mole with an asymmetrical appearance is a potential indication of skin malignancy. Asymmetry, where one half of the mole does not match the other, is one of the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving size, shape, or color) of melanoma detection.
Choice D rationale
The presence of a papule, a small, raised bump on the skin, is not necessarily indicative of skin cancer. Papules can be a sign of many different skin conditions, including acne, skin infections, or dermatitis.
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