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?

Call for assistance.

Assist the patient in sitting down on the bed.

Assess the vital signs for orthostatic hypotension.

Notify the provider

Answer and Explanation

The Correct Answer is B

A. Call for assistance. While calling for help may be necessary if the patient becomes unresponsive or falls, the priority action is to ensure their safety immediately by helping them sit down.

B. Assist the patient in sitting down on the bed. The patient is experiencing dizziness upon standing, which could indicate orthostatic hypotension or another condition. The best immediate action is to help them sit down to prevent a fall or further complications.

C. Assess the vital signs for orthostatic hypotension. While assessing for orthostatic hypotension is important, it should be done after ensuring the patient is safe by sitting them down.

D. Notify the provider. The provider may need to be informed if the dizziness persists or if there is an underlying medical issue. Still, immediate intervention (sitting the patient down) takes priority before notifying the provider.

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Correct Answer is D

Explanation

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

A. A 32-year-old with menstrual cramps. B. A78-year-old with peripheral arterial disease. C. A44 year old with a hematoma to the leg D. A 69-year-old with a pulled muscle

Correct Answer is B

Explanation

A. A 32-year-old with menstrual cramps. Cold therapy can help relieve pain and reduce pelvic inflammation.

B. A 78-year-old with peripheral arterial disease. Cold therapy causes vasoconstriction, which can further reduce circulation in clients with PAD, increasing the risk of tissue damage.

C. A 44-year-old with a hematoma to the leg: Cold therapy is recommended for hematomas as it reduces swelling and bleeding.

D. A 69-year-old with a pulled muscle: Cold therapy reduces inflammation and numbs pain, making it beneficial for muscle injuries.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

Which of the following clients should avoid the use of cold therapy?

Correct Answer is B

Explanation

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?

A patient lives in a rural area and requires frequent appointments related to their health condition. Which of the following interventions should the nurse facilitate?

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A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?