NUR 242 Exam #2 updated solutions

While making rounds, the nurse finds a patient on the floor in the hallway. Which action will the nurse do first? -assess the patient for injury -transfer the patient back to bed -assist the patient to a wheelchair -report the patient's condition to the physician - ans -----assess the patient for injury Which action should the nurse take to prevent accidents? -apply a restraint when the patient is in the wheelchair to keep them from falling -determine the strength of the patient -turn all the lights off in the room so the patient can sleep -provide a cane for walking if the patient is weak - ans -----determine the strength of the patient When caring for a patient who is able to get out of bed independently and safely, the nurse will -leave one side rail at the foot of the bed up -leave one side rail up when there are only two side rails on the bed -leave both side rails up in a two side rail bed -leave all four side rails up for all patients at all times - ans -----leave one side rail up when there are only two side rails on the bed The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? -a sponge is left in the patient's incision -pulmonary embolism after lung surgery -no blood incompatibility occurs with a blood transfusion -development of stage II pressure ulcer - ans -----a sponge is left in the patient's incision