you see a patient lying on the loor of the bathroom you are not assigned to this patient what is the irst thing that you should do
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NCLEX-RN

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1. You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

Correct answer: C

Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.

2. Which of the following is one of the three smallest bones in the body?

Correct answer: C

Rationale: The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.

3. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?

Correct answer: C

Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.

4. In which of these patients would rectal temperatures be measured?

Correct answer: B

Rationale: Rectal temperature measurement is preferred in situations where other routes are impractical or when the most accurate measure is necessary, such as in critically ill patients. The rectal route may be chosen due to its reliability in such cases. For older adults, school-age children, and patients receiving oxygen via nasal cannula, rectal temperature measurement is not typically indicated. Other routes like oral, tympanic, or axillary measurements are more commonly used in these populations due to comfort, convenience, and non-invasive nature.

5. One major difference between long term care and respite centers is the fact that long term care facilities:

Correct answer: C

Rationale: The major difference between long-term care and respite centers is that long-term care facilities provide both physical and emotional care on an ongoing, long-term basis. This continuous care is essential for residents who require extended assistance. In contrast, respite centers offer temporary services, providing similar care but for a short-term duration. These short-term services are designed to give family caregivers a break from their daily responsibilities. Choice A is incorrect because both long-term care and respite centers can offer both physical and emotional care, but the key distinction lies in the duration of care provided. Choice B is incorrect as respite centers do not typically offer outpatient services, and the focus is on temporary relief rather than long-term care. Choice D is incorrect as the question clearly highlights a major difference between long-term care and respite centers.

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