A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Assess the patient.

File a safety event report

Place the patient on fall precautions.

Get the patient back to bed.

Answer and Explanation

The Correct Answer is A

A. Assess the patient: The priority action is to assess the patient for injuries before taking any further steps.

B. File a safety event report: This is important but should be done after assessing and ensuring the patient’s safety.

C. Place the patient on fall precautions: While necessary, this is a secondary intervention after assessment and ensuring immediate safety.

D. Get the patient back to bed: Moving the patient before assessing for injuries could worsen potential fractures or other injuries.

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Correct Answer is B

Explanation

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

A. Avoid using your fingers to open the mouth. B. Apply moisturizer to the oral mucosa and lips. C. Brush the teeth with a soft bristled toothbrush D. Use a toothbrush with a suction attachment

Correct Answer is D

Explanation

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

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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)

A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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

Correct Answer is D

Explanation

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