A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs.

Keep the patient standing and call for assistance to continue to move with the help of another nurse.

Have the patient sit down on the bed and dangle her feet for a few seconds and then attempt the move again.

Continue to walk the patient to the chair and if the patient faints, lower them gently to the floor.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Correct answer: C

C. The nurse turns and their back is facing the sterile field.Turning one’s back to the sterile field is a breach of sterile technique because it increases the risk of contamination. The sterile field must always be in the nurse’s line of sight to ensure it remains uncontaminated.

Incorrect Options:

A. The nurse applies sterile gloves and touches a sterile object in the sterile field.This is correct practice. Sterile gloves are used to handle sterile objects within the sterile field to maintain sterility.

B. The nurse disposes of an opened container of sterile saline after 24 hours.This is correct practice. Sterile saline should be discarded after 24 hours to prevent contamination.

D. The nurse keeps hands above waist level while donning sterile gloves.This is correct practice. Keeping hands above waist level helps maintain sterility by preventing contact with non-sterile surfaces.

A. Cleanse the catheter from the meatus outward using mild soap and warm water. B. Use the same cleansing cloth for cleaning of the perineal area and the catheter tubing. C. Use chlorhexidine gluconate (CHG) to cleanse the perineal area

Correct Answer is A

Explanation

The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new perioperative nurse is being educated regarding surgical asepsis. What observations by the preceptor would indicate that there is a need for further education and reinforcement of the principles of asepsis?

Correct Answer is C

Explanation

The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?

Correct Answer is A

Explanation

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

A patient develops food poisoning from contaminated food. The contaminated food would be an example of which part of the infectious cycle?

A nurse is caring for a client who has a history of falling at their assisted living facility. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall?

Exhibits The physician orders Lanoxin elixir 90 mcg PO every morning. Drug available: Lanoxin elixir 0.05 mg/mL How many mL will be given?

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

Which of the following scenarios would represent proper delegation as applies to delegating care to the right professional?