A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?
Ensure the patient is safe and leave to get them some water.
Contact dietary to order the patient a full liquid meal.
Request that the provider write the order in the chart.
Record the information in the patient chart.
The Correct Answer is C
A. Ensure the patient is safe and leave to get them some water: The provider’s verbal statement is not an official order. The student nurse must ensure a written order is in place before implementing dietary changes.
B. Contact dietary to order the patient a full liquid meal: The student nurse cannot place orders. They must first verify that the provider has documented the order.
C. Request that the provider write the order in the chart: Orders must be documented in the patient’s medical record before they can be carried out. The student nurse should ensure the provider formally writes the order.
D. Record the information in the patient chart: The student nurse cannot chart an order that has not been officially written by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.
B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.
C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.
D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.
Correct Answer is B
Explanation
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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