You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.
What is your first step in the nursing process in this situation?
Leave the patient to get help.
Call the patient’s health-care provider from your cell phone.
Help the patient get up and then document your findings in the chart.
Gather more information by making observations about the patient.
The Correct Answer is D
The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other
The other options do not represent the first step in the nursing process and may not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement shows that the nurse is interested in Linda's feelings and is willing to listen to her. It allows Linda to express her emotions and concerns, which can help to reduce her anxiety.
Option A ("How about watching a football game?") may not be appropriate as Linda may not be interested in football or may not find it helpful in reducing her anxiety.
Option B ("What do you have to be upset about now?") is not a therapeutic statement as it can be perceived as dismissive and invalidating of Linda's feelings.
Option D ("Ignore the client.") is never an appropriate approach for a nurse or any healthcare professional as it goes against the principles of providing care and support to patients.
Correct Answer is ["2"]
Explanation
The nurse will administer 2 tablets of Zyprexa 7.5 mg to equal the ordered dose of Zyprexa 15 mg. Explanation:
"PO" stands for "by mouth" and "HS" stands for "at bedtime". The medication order is for Zyprexa 15 mg to be taken orally at bedtime for the treatment of psychosis. The nurse has Zyprexa 7.5 mg tablets available.
To determine how many tablets the nurse should administer, we need to do a dose calculation. We know that the ordered dose is 15 mg and the available dose is 7.5 mg. Therefore, we can set up a proportion:
7.5 mg / 1 tablet = 15 mg / x tablets Solving for x, we can cross-multiply:
7.5 mg * x tablets = 15 mg * 1 tablets x = 15 mg / 7.5 mg
x = 2 tablets
Therefore, the nurse should administer 2 tablets of Zyprexa 7.5 mg to equal the ordered dose of Zyprexa 15 mg.
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