Practice Quiz

NCLEX-RN

Category - Basic Care

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The client underwent a hysterectomy two days ago. The nurse noted that the client was able to tolerate sitting on the bed. One afternoon, the client asks the nurse to assist her to the bathroom. On the way to the bathroom the client tells the nurse that she feels she is about to faint. The next action of the nurse is to:
  1. Immediately return the client to the bed.
  2. Lower the client on the floor.
  3. Assess the client’s physical appearance.
  4. Keep the client steady before continuing ambulating.
Explanation
Answer: B - The nurse’s initial action when the client says she is about to faint during ambulation is to gently lower the client to the floor. This is the safest intervention if a bed or chair is not close by. Keeping the client steady, continuing to ambulate, and returning the client to the bed are unsafe. The client should be placed flat on the floor with the legs slightly elevated, if not contraindicated, to promote venous return. An assessment of the client’s physical appearance and vital signs should be completed by the nurse after ensuring the client’s safety.
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