A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?
Call for assistance.
Assist the patient in sitting down on the bed.
Assess the vital signs for orthostatic hypotension.
Notify the provider
The Correct Answer is B
A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.
B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.
C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.
D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.
B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.
C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.
D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.
Correct Answer is B
Explanation
A. Protective prone: The prone position (lying on the stomach) does not allow easy enema administration and is not recommended.
B. Left lateral recumbent: The left lateral position allows gravity to assist with enema administration and helps the fluid move efficiently through the colon.
C. High Fowler's: Sitting upright does not promote proper enema flow, making it ineffective.
D. Dorsal recumbent: Lying on the back does not facilitate enema administration effectively.
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