The nurse has delegated to nursing assistive personnel (NAP) the skill
of assisting with a bedpan for a patient who has had discomfort when
walking to the bathroom. Which statement made by the NAP requires
the nurse's follow-up?
A. "Do you still need a stool sample for the lab?"
B. "If I can get someone to help, I'll walk her to the bathroom."
C. "The patient reports that moving is uncomfortable for her. Has she
had pain medication recently?"
D. "The patient told me that she's had problems with haemorrhoids in the
past." - ANSWER B. "If I can get someone to help, I'll walk her to the
bathroom."
(Rationale: The NAP is not qualified to determine whether it is
appropriate to ambulate the patient. The nurse has delegated the skill of
assisting with a bedpan, and the NAP should carry out that responsibility
as instructed. It is appropriate for the NAP to ask whether a stool sample
is required. It is appropriate for the NAP to share the patient's report of
pain and to inquire about medication. Since walking is known to be
painful for the patient, it stands to reason that she might be
uncomfortable simply moving about in bed. It is appropriate for the NAP
to share with the nurse any information pertaining to the patient's
toileting.)
A patient with a nasogastric tube, an intravenous infusion line, and an
indwelling urinary catheter needs to be placed on the bedpan. Which
action would the nurse take first to ensure the patient's safety?
A. Close the bedside curtain.
B. Raise the side rail on the side opposite that on which the nurse is
working.
C. Obtain help to place the patient on the bedpan.
D. Raise the bed to a comfortable working height. - ANSWER C. Obtain
help to place the patient on the bedpan.
,(Rationale: For a patient with a drain, tube, or intravenous line, the
nurse's first action to ensure the patient's safety would be to obtain help
to place her on the bedpan. Closing the bedside curtain is appropriate
but provides for the patient's privacy, not her safety. Raising the side rail
to keep the patient from falling out of bed as she rolls on or off the
bedpan is an appropriate safety measure but is not the first action the
nurse would take. Raising the bed to a comfortable working height
provides for the safety of the nurse, not the patient.)
A dependent, confused patient is being given a bedpan. How can the
nurse best ensure the patient's safety?
A. Respond promptly to the call light.
B. Raise the side rails on the bed before leaving the room.
C. Slide one hand under the patient's sacrum to help the patient lift off
the bedpan.
D. Check in on the patient every 5 minutes until the bedpan can be
removed. - ANSWER B. Raise the side rails on the bed before leaving
the room.
(Rationale: Raising the side rails on the bed is the best safety
intervention to minimize the risk of falling if the patient attempts to get
out of bed without assistance. Responding promptly to the call light is
important for patient safety, but this patient is confused and may not
know how to use the device. The patient is dependent but confused, and
he or she can participate in the effort to move on or off the bedpan. The
technique selected to help the patient off the bedpan is irrelevant to the
patient's safety. Checking the patient is appropriate but does not ensure
safety while the patient is alone. Five minutes is plenty of time for the
patient to try to get out of bed unassisted if one or both side rails are left
down.)
The nurse is assisting with a bedpan for a patient who had knee surgery
24 hours ago. What is the best way for the nurse to maximize comfort
while the patient uses the bedpan?
A. Raise the knee gatch.
B. Offer a dose of the patient's prescribed oral pain medication.
C. Evaluate the patient's ability to move in bed.
, D. Elevate the head of the bed to between 30 and 60 degrees. -
ANSWER D. Elevate the head of the bed to between 30 and 60
degrees.
After assisting with a bedpan, the nurse notes that the patient's stool is
streaked with bright-red blood. What would the nurse do first?
A. Notify the patient's health care provider.
B. Ask if the patient has a history of hemorrhoids.
C. Check the medical record to see if the patient has a history of blood in
the stool.
D. Document the observation in the medical record, indicating a need for
follow-up. - ANSWER B. Ask if the patient has a history of hemorrhoids.
(Rationale: Asking whether the patient has a history of hemorrhoids is
the most appropriate initial response, followed by documentation of the
observation and notification of the patient's health care provider.
Although the nurse would promptly report this observation to the
patient's health care provider, doing so would not be the nurse's first
action. It is appropriate for the nurse to review the patient's record to see
if this observation were a new finding, doing so would not be the nurse's
first action. The nurse would promptly document this observation; doing
so would not be the nurse's first action.)
A male patient on bed rest is permitted to stand to use the urinal. Which
action would the nurse take to ensure his safety before helping him to a
standing position?
A. Determine his risk for orthostatic hypotension
B. Assess his genitals for signs of impaired skin integrity
C. Ask him to demonstrate proper use of a urinal
D. Instruct him to use the call light when he is finished - ANSWER A.
Determine his risk for orthostatic hypotension
(Rationale: Since the patient is on bed rest, he is at risk for orthostatic
hypotension. Assessing for this condition would help ensure that the
patient could stand safely to use the urinal. Assessing for impaired skin
integrity is a nursing responsibility, but it does not pertain to patient
safety while standing to use a urinal. Demonstrating proper use of a
urinal pertains to patient education, not patient safety. The nurse is
unlikely to give an instruction to use the call light, since it is not safe to
leave the patient while he is standing at the bedside using the urinal.)
of assisting with a bedpan for a patient who has had discomfort when
walking to the bathroom. Which statement made by the NAP requires
the nurse's follow-up?
A. "Do you still need a stool sample for the lab?"
B. "If I can get someone to help, I'll walk her to the bathroom."
C. "The patient reports that moving is uncomfortable for her. Has she
had pain medication recently?"
D. "The patient told me that she's had problems with haemorrhoids in the
past." - ANSWER B. "If I can get someone to help, I'll walk her to the
bathroom."
(Rationale: The NAP is not qualified to determine whether it is
appropriate to ambulate the patient. The nurse has delegated the skill of
assisting with a bedpan, and the NAP should carry out that responsibility
as instructed. It is appropriate for the NAP to ask whether a stool sample
is required. It is appropriate for the NAP to share the patient's report of
pain and to inquire about medication. Since walking is known to be
painful for the patient, it stands to reason that she might be
uncomfortable simply moving about in bed. It is appropriate for the NAP
to share with the nurse any information pertaining to the patient's
toileting.)
A patient with a nasogastric tube, an intravenous infusion line, and an
indwelling urinary catheter needs to be placed on the bedpan. Which
action would the nurse take first to ensure the patient's safety?
A. Close the bedside curtain.
B. Raise the side rail on the side opposite that on which the nurse is
working.
C. Obtain help to place the patient on the bedpan.
D. Raise the bed to a comfortable working height. - ANSWER C. Obtain
help to place the patient on the bedpan.
,(Rationale: For a patient with a drain, tube, or intravenous line, the
nurse's first action to ensure the patient's safety would be to obtain help
to place her on the bedpan. Closing the bedside curtain is appropriate
but provides for the patient's privacy, not her safety. Raising the side rail
to keep the patient from falling out of bed as she rolls on or off the
bedpan is an appropriate safety measure but is not the first action the
nurse would take. Raising the bed to a comfortable working height
provides for the safety of the nurse, not the patient.)
A dependent, confused patient is being given a bedpan. How can the
nurse best ensure the patient's safety?
A. Respond promptly to the call light.
B. Raise the side rails on the bed before leaving the room.
C. Slide one hand under the patient's sacrum to help the patient lift off
the bedpan.
D. Check in on the patient every 5 minutes until the bedpan can be
removed. - ANSWER B. Raise the side rails on the bed before leaving
the room.
(Rationale: Raising the side rails on the bed is the best safety
intervention to minimize the risk of falling if the patient attempts to get
out of bed without assistance. Responding promptly to the call light is
important for patient safety, but this patient is confused and may not
know how to use the device. The patient is dependent but confused, and
he or she can participate in the effort to move on or off the bedpan. The
technique selected to help the patient off the bedpan is irrelevant to the
patient's safety. Checking the patient is appropriate but does not ensure
safety while the patient is alone. Five minutes is plenty of time for the
patient to try to get out of bed unassisted if one or both side rails are left
down.)
The nurse is assisting with a bedpan for a patient who had knee surgery
24 hours ago. What is the best way for the nurse to maximize comfort
while the patient uses the bedpan?
A. Raise the knee gatch.
B. Offer a dose of the patient's prescribed oral pain medication.
C. Evaluate the patient's ability to move in bed.
, D. Elevate the head of the bed to between 30 and 60 degrees. -
ANSWER D. Elevate the head of the bed to between 30 and 60
degrees.
After assisting with a bedpan, the nurse notes that the patient's stool is
streaked with bright-red blood. What would the nurse do first?
A. Notify the patient's health care provider.
B. Ask if the patient has a history of hemorrhoids.
C. Check the medical record to see if the patient has a history of blood in
the stool.
D. Document the observation in the medical record, indicating a need for
follow-up. - ANSWER B. Ask if the patient has a history of hemorrhoids.
(Rationale: Asking whether the patient has a history of hemorrhoids is
the most appropriate initial response, followed by documentation of the
observation and notification of the patient's health care provider.
Although the nurse would promptly report this observation to the
patient's health care provider, doing so would not be the nurse's first
action. It is appropriate for the nurse to review the patient's record to see
if this observation were a new finding, doing so would not be the nurse's
first action. The nurse would promptly document this observation; doing
so would not be the nurse's first action.)
A male patient on bed rest is permitted to stand to use the urinal. Which
action would the nurse take to ensure his safety before helping him to a
standing position?
A. Determine his risk for orthostatic hypotension
B. Assess his genitals for signs of impaired skin integrity
C. Ask him to demonstrate proper use of a urinal
D. Instruct him to use the call light when he is finished - ANSWER A.
Determine his risk for orthostatic hypotension
(Rationale: Since the patient is on bed rest, he is at risk for orthostatic
hypotension. Assessing for this condition would help ensure that the
patient could stand safely to use the urinal. Assessing for impaired skin
integrity is a nursing responsibility, but it does not pertain to patient
safety while standing to use a urinal. Demonstrating proper use of a
urinal pertains to patient education, not patient safety. The nurse is
unlikely to give an instruction to use the call light, since it is not safe to
leave the patient while he is standing at the bedside using the urinal.)
