The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

Applies non skid socks before getting the patient out of bed.

Activates the chair alarm when the patient is sitting in the chair.

Ensures that the bed is in the lowest position prior to leaving the room.

Places the patient on bedrest.

Answer and Explanation

The Correct Answer is D

A. Applies non-skid socks before getting the patient out of bed: Non-skid socks help prevent slipping and are an appropriate fall precaution.

B. Activates the chair alarm when the patient is sitting in the chair: Chair alarms alert staff if the patient attempts to get up unassisted, reducing fall risk.

C. Ensures that the bed is in the lowest position prior to leaving the room: Keeping the bed low reduces the severity of injury in case of a fall.

D. Places the patient on bed rest: Bed rest is not a standard fall precaution unless medically necessary. It can lead to deconditioning and further weakness, increasing fall risk.

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Correct Answer is C

Explanation

A. It is painful to sit on a bedpan. Discomfort may be a factor, but pain alone does not explain the difficulty in having a bowel movement.
B. The position encourages the Valsalva maneuver. The Valsalva maneuver (straining against a closed airway) can occur in any position, but posture is the primary problem here.
C. The position does not facilitate downward pressure. The seated position allows for gravity and proper abdominal muscle engagement, making defecation easier. Lying down does not facilitate intra-abdominal pressure.
D. The cause is unknown and requires further study. The relationship between position and defecation is well understood in physiology.

A. Applying sterile gloves to assist with a procedure. B. Inserting an indwelling urinary catheter. C. Preparing injectable medications. D. Picking up soiled tissues off of the bedside table.

Correct Answer is D

Explanation

A. Applying sterile gloves to assist with a procedure: This is part of surgical asepsis (sterile technique) rather than medical asepsis.
B. Inserting an indwelling urinary catheter: This requires sterile technique, not just medical asepsis.
C. Preparing injectable medications: Medication preparation requires aseptic (sterile) technique to prevent contamination.
D. Picking up soiled tissues off of the bedside table: Medical asepsis includes hand hygiene and proper handling of contaminated items to prevent the spread of infection.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is having difficulty having a bowel movement laying on the bedpan. What is the physiologic reason for this problem?

Correct Answer is C

Explanation

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

Correct Answer is D

Explanation

A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

What are three positive results of meaningful use compliance in the Electronic Health Record?

The nurse is assessing the patient's output for the shift. What finding is most concerning?

The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

The student nurse is conducting a health history for a patient recently diagnosed with cancer. What statement made by the student would require remediation by the clinical faculty?

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?