The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which priority action should the nurse take next?
Do nothing, no harm has occurred
Notify the health care provider
Assess the patient further
Complete an incident report
The Correct Answer is B
Choice A reason: Doing nothing is inappropriate, as a fall risks injury (e.g., fractures, head trauma), even if no harm is immediately apparent. Notifying the provider ensures further evaluation and intervention, making this choice unsafe and negligent for patient safety.
Choice B reason: Notifying the health care provider is the priority after a fall, as it ensures medical evaluation for potential injuries (e.g., concussion, fractures) not evident in initial assessment. Prompt reporting facilitates timely intervention, making this the most critical next step for patient safety.
Choice C reason: Further assessment is important, but the initial assessment has been done. Notifying the provider takes precedence to ensure medical oversight for hidden injuries, as falls in healthcare settings require professional evaluation, making this a secondary action.
Choice D reason: Completing an incident report is necessary for documentation and quality improvement but is not the priority over clinical care. Notifying the provider ensures immediate medical attention for potential injuries, making reporting a follow-up action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Bananas are high in potassium, contraindicated for a low-potassium diet. They can elevate serum potassium, risking hyperkalemia, making this an incorrect choice for the diet plan.
Choice B reason: White rice is low in potassium, making it suitable for a low-potassium diet. It provides carbohydrates without significantly affecting potassium levels, making it the correct food to include.
Choice C reason: Spinach is high in potassium, inappropriate for a low-potassium diet. Consuming it could exacerbate hyperkalemia, making this incorrect for a patient requiring potassium restriction.
Choice D reason: Potatoes are high in potassium, unsuitable for a low-potassium diet. They increase potassium intake, risking imbalance, making this an incorrect choice for the client’s dietary plan.
Correct Answer is D
Explanation
Choice A reason: Hydrogen peroxide can damage healthy tissue and delay healing in stage 3 pressure ulcers. Normal saline or prescribed solutions are preferred, making this an incorrect intervention for wound care.
Choice B reason: Massaging reddened areas risks further tissue damage, as pressure exacerbates ischemia in stage 3 ulcers. Avoiding pressure is critical, making this an incorrect and harmful intervention for care.
Choice C reason: Applying a heat lamp can dry the wound and cause burns, delaying healing. Moist wound environments promote recovery, making heat application inappropriate for stage 3 pressure ulcer management.
Choice D reason: Repositioning every 2 hours relieves pressure on stage 3 ulcers, promoting blood flow and preventing further tissue damage. This is a key intervention for healing, making it the correct choice.
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