The nurse is caring for a client and the following sequence of events occur:. 1428: BP: 88/36 mm Hg. 1430: Dr. Jones paged.

1445: No return call from Dr. Jones.

1450: BP 90/40 mm Hg. 1455: Dr. Jones paged and charge nurse notified.

1505: No return call from Dr. Jones.

What should the nurse document in the patient's chart regarding the sequence of events described above?

Dr. Jones paged at 1430 and 1455 about low blood pressure readings.

No return call from Dr. Jones.

Patient and family informed that Dr. Jones may not call back.

Dr. Jones paged at 1430 of patient's BP 88/36 mm Hg. Repeat BP at 1450 90/40 mm Hg. Dr. Jones paged at 1455.

No orders received.

Answer and Explanation

The Correct Answer is B

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Correct Answer is C

Explanation

Choice C rationale:

When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.

Choice A rationale:

Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.

Choice B rationale:

Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.

Choice D rationale:

Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.

A. An adult patient who has left arm weakness secondary to a childhood injury. B. An elderly patient who requires eye glasses for reading small print on labels and newspapers. C. A patient who is confused and experiencing nausea due to a head injury. D. A patient who uses the grab bars located in the hospital bathroom.

Correct Answer is C

Explanation

Choice A rationale:

While a patient with left arm weakness may have some mobility limitations, it does not necessarily put them at the highest risk for falling compared to the other options provided.

Choice B rationale:

Needing glasses for reading small print does not directly indicate a high risk of falling. The patient can still have good overall mobility and balance.

Choice C rationale:

A confused patient experiencing nausea due to a head injury is at the highest risk for falling. Confusion impairs judgment and decision-making abilities, increasing the likelihood of accidents. Nausea can further destabilize the patient, making them prone to falls.

Choice D rationale:

Using grab bars in the hospital bathroom indicates that the patient is aware of their limitations and is taking precautions to prevent falls. This does not suggest a higher risk compared to a confused and nauseous patient.

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Naxlex Comprehensive Predictor Exams

A patient with Covid has been bedridden for the last 2 weeks.What effects does the nurse expect to find in a patient who has had minimal activity and mobility for 2 weeks?

Correct Answer is C

Explanation

The nurse is caring for several patients on a medical unit.Which patient does the nurse identify as being most at risk for falling?

Correct Answer is C

Explanation

The nurse is instructing a patient about safety with oxygen in the home setting.What would the nurse include in the instructions?

Which statement regarding the anatomy and physiology of the respiratory system is correct?

The physician has ordered a medication for a patient that is twice the normal dosage of the medication.If the nurse harms a patient by administering the medication, as ordered by the physician, which is true?

The newly admitted patient has contractures of both lower extremities.What nursing intervention should be included in this patient's plan of care?

A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.Which action is appropriate for the nurse to conduct for a patient in restraints?

The nurse is implementing interventions to reduce the number of falls in the health care facility.What action is best for the nurse to implement?

A nurse uses the SBAR method to give report about a patient to another unit in the hospital.What statement by the nurse would the nurse identify as the "situation" portion of the SBAR report?