The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?

The patient is grouchy and inappropriate, always causing trouble for the nurses.

The patient’s nurse assistant always took her time to answer his call lights.

The patient probably urinated on the floor and slipped on the wet floor.

The patient was found on the floor and his urinal was on the floor next to him.

Answer and Explanation

The Correct Answer is D

Choice A reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.

Choice B reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.

Choice C reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.

Choice D reason: This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The Agency for Healthcare Research and Quality is a federal agency that supports research and improvement of health care quality and safety, but it does not provide treatment guidelines for acetaminophen overdose.

Choice B reason: This is correct. The American Association of Poison Control Centers is a national organization that provides poison information and treatment recommendations through a network of poison centers. The nurse can call the poison center at 1-800-222-1222 to get expert advice on how to manage the patient who took 60 acetaminophen tablets.

Choice C reason: This is incorrect. The Centers for Disease Control and Prevention is a federal agency that monitors and prevents diseases and public health threats, but it does not provide treatment guidelines for acetaminophen overdose.

Choice D reason: This is incorrect. The Institute for Safe Medication Practices is a nonprofit organization that promotes safe medication practices and error prevention, but it does not provide treatment guidelines for acetaminophen overdose.

A. The patient who is nauseated and vomiting after receiving narcotic pain medication. B. The patient who is waiting for discharge teaching in order to go home. C. The patient with chest pain after two doses of sublingual nitroglycerin. D. The constipated patient who needs to use the toilet after receiving a laxative.

Correct Answer is C

Explanation

Choice A reason: This is an incorrect choice because the patient who is nauseated and vomiting after receiving narcotic pain medication is not the most urgent patient. Nausea and vomiting are common side effects of narcotic pain medication and can be managed with antiemetics and hydration. The patient's condition is not life-threatening and does not require immediate intervention.

Choice B reason: This is an incorrect choice because the patient who is waiting for discharge teaching in order to go home is not the most urgent patient. Discharge teaching is an important part of patient education and care transition, but it can be delayed until the more critical patients are attended to. The patient's condition is stable and does not require immediate intervention.

Choice C reason: This is the correct choice because the patient with chest pain after two doses of sublingual nitroglycerin is the most urgent patient. Chest pain is a sign of myocardial ischemia, which can lead to myocardial infarction or heart attack. Sublingual nitroglycerin is a medication that dilates the coronary arteries and relieves chest pain. If the chest pain persists after two doses of sublingual nitroglycerin, the patient may have unstable angina or acute coronary syndrome, which are medical emergencies that require immediate intervention⁴.

Choice D reason: This is an incorrect choice because the constipated patient who needs to use the toilet after receiving a laxative is not the most urgent patient. Constipation is a common gastrointestinal problem that can be treated with laxatives and dietary changes. The patient's condition is not life-threatening and does not require immediate intervention.

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The nurse is completing the charting after a patient suffered a fall. Which statement is appropriate for the nurse to include in the description of the incident?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Correct Answer is B

Explanation

Which patient’s needs must be addressed first by the registered nurse?

Correct Answer is C

Explanation

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