The nurse is assisting an elderly patient with an unsteady gait to the bedside commode. The patient loses their balance and falls to the floor. What is the nurse’s first response?
Notify the physician of the patient fall
Assess the patient for injuries
Contact the family about the patient
Complete the incident report
The Correct Answer is B
Choice A reason: Notifying the physician is important, but it is not the immediate first step. Before contacting providers, the nurse must determine whether the patient sustained injuries and provide urgent care if needed.
Choice B reason: The first response is to assess the patient for injuries. Safety and immediate clinical evaluation take priority after a fall. The nurse must check for fractures, bleeding, neurological changes, or pain before moving the patient. This ensures that appropriate interventions are initiated promptly.
Choice C reason: Contacting the family is part of communication after the patient is stabilized and assessed. It is not the first priority because family notification does not address immediate patient safety.
Choice D reason: Completing an incident report is required for documentation and quality improvement, but it is done after the patient’s condition is stabilized and care needs are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement requires further education because patients with diabetes should never walk barefoot, even for a short period. Neuropathy and poor circulation increase the risk of unnoticed injuries, infections, and ulcers. Walking barefoot exposes the feet to trauma, cuts, and burns, which may not heal properly and can lead to severe complications such as gangrene or amputation.
Choice B reason: This statement is correct because patients with diabetes must promptly report any changes in their feet, such as bumps, redness, or sores. Early detection of problems allows for timely intervention and prevents progression to serious infections or ulcers.
Choice C reason: This statement is correct because daily foot inspection, including the soles and between the toes, is essential. Many diabetic patients develop neuropathy and may not feel injuries. Regular inspection ensures that issues are identified early before they worsen.
Choice D reason: This statement is correct because daily washing and thorough drying of the feet helps prevent fungal infections and maintains skin integrity. Special attention should be given to drying between the toes to avoid moisture buildup, which can lead to infection.
Correct Answer is D
Explanation
Choice A reason: Administering PRBCs is outside the scope of practice for LPNs in most jurisdictions. Blood transfusions require RN-level training and monitoring due to the risk of severe transfusion reactions.
Choice B reason: While it is correct that administering PRBCs is outside the LPN’s scope, simply refusing without ensuring patient safety is not appropriate. The LPN must escalate the order to the RN or charge nurse to ensure the patient receives timely care.
Choice C reason: Delegating vital signs to a nurse’s aide while administering PRBCs is unsafe and outside the LPN’s scope. The LPN cannot administer blood products, and vital signs during transfusion must be closely monitored by a licensed nurse.
Choice D reason: The correct action is for the LPN to take vital signs and then ask the charge RN to administer the PRBCs. This ensures patient safety, complies with the Nurse Practice Act, and maintains proper delegation.
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