NCLEX-RN (Registered Nurse) Practice Exam · Question
Which finding requires immediate intervention by the nurse during rounds?
A confused patient attempting to climb out of bed is at high risk for falls and injury, requiring immediate intervention to ensure safety.
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Question: Which finding requires immediate intervention by the nurse during rounds?
Answer options:
- A patient with a pain level of 6/10 after pain medication.
- A patient requesting assistance to the bathroom.
- A patient's IV site with slight redness and tenderness. ✅ A patient confused and attempting to climb out of bed.
Correct answer: A patient confused and attempting to climb out of bed.
Explanation: A confused patient attempting to climb out of bed is at high risk for falls and injury, requiring immediate intervention to ensure safety.
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