On the first day at 1830, certain medical procedures were initiated for the patient.
Which of the following procedures were likely to have been initiated based on the patient’s condition?

Initiation of peripheral IV access

X-ray of left shoulder and right knee, STAT

Computed tomography (CT) of brain, STAT

Administration of pain medication .

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale

Initiation of peripheral IV access is a common procedure in the emergency department for patients who have experienced a fall. This allows for the administration of fluids and medications as needed.

Choice B rationale

An X-ray of the left shoulder and right knee would likely be ordered given the patient’s report of pain in his left shoulder after the fall. This would help to identify any fractures or other injuries.

Choice C rationale

A CT scan of the brain may not be necessary in this case, unless the patient was experiencing symptoms such as confusion, loss of consciousness, or other neurological signs following the fall.

Choice D rationale

Administration of pain medication would likely be initiated based on the patient’s report of pain.

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Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

A. Replace paper trash bags with plastic biohazard bags. B. Remove soft drink cans from the nurse’s desk and patient lounge. C. Confiscate the patient’s cellular phone and provide a room telephone. D. Ensure that prescribed medications are securely stored in the room.

Correct Answer is D

Explanation

Choice A rationale

Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.

Choice B rationale

Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.

Choice C rationale

Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.

Choice D rationale

Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.

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On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.Which action should the nurse take to ensure a safe environment for this patient?

Correct Answer is D

Explanation

On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

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On the first day at 1830, certain medical procedures were initiated for the patient.
Which of the following procedures were likely to have been initiated based on the patient’s condition?