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 A
Explanation
Choice A rationale
Granulation tissue covering the wound bed is a positive sign of wound healing. Granulation tissue is a key component of the wound healing process, typically forming during the proliferation phase. It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury. Therefore, the presence of granulation tissue covering the wound bed indicates an improvement in the patient’s condition.
Choice B rationale
Slight erythema at the wound edges could be a sign of inflammation or infection. Erythema, or redness of the skin, is often associated with inflammation or infection. While it can be a normal part of the healing process, persistent or increasing erythema could indicate a problem such as infection or irritation. Therefore, slight erythema at the wound edges does not necessarily indicate an improvement in the patient’s condition.
Choice C rationale
The surrounding tissue being warm to touch could be a sign of inflammation or infection. When skin feels hot to the touch, it often means that the body’s temperature is hotter than normal. This can happen due to an infection or an illness, but it can also be caused by an
environmental situation that increases body temperature. Therefore, the surrounding tissue being warm to touch does not necessarily indicate an improvement in the patient’s condition.
Choice D rationale
The patient reporting pain as a 2 on a scale from 0 to 10 could indicate that the patient’s pain is minor. On a pain scale, a score of 2 usually indicates minor pain. However, pain is a subjective experience and can vary greatly among individuals. Therefore, while a lower pain score generally suggests less severe pain, it does not necessarily indicate an improvement in the patient’s overall condition.
Correct Answer is C
Explanation
Choice A rationale
Assisting the patient into a prone position is not necessary for the use of thigh-length sequential compression sleeves. These devices are typically used while the patient is in bed or sitting in a chair.
Choice B rationale
Placing a sleeve over the top of each leg with the opening facing up is not the correct method for applying sequential compression sleeves. The sleeves should be applied so that they fit snugly and comfortably around the patient’s legs.
Choice C rationale
The nurse should ensure that two fingers can fit under the sleeves. This is to ensure that the sleeves are not too tight, which could impede blood flow and cause discomfort or injury to the patient.
Choice D rationale
Setting the ankle pressure at 65 mm Hg is not related to the use of sequential compression sleeves. The pressure settings for these devices are typically determined by the healthcare provider based on the patient’s specific needs.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.