A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Notify the client's provider.

Measure the client's vital signs.

Complete an incident report.

Document the fall in the client's medical record.

Answer and Explanation

The Correct Answer is B

When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
A.   Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
C.   Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
D.   Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.

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Correct Answer is D

Explanation

Swelling of the lips

The nurse should reinforce with the client that the epinephrine auto-injector can help treat swelling of the lips. Epinephrine is a medication commonly used to treat severe allergic reactions, also known as anaphylaxis. Swelling of the lips is one of the hallmark manifestations of an allergic reaction.

Epinephrine acts quickly to reverse the allergic response by constricting blood vessels, relaxing smooth muscles, and reducing swelling and inflammation.

Nausea in (option A) is incorrect: Nausea can have various causes, and epinephrine is not specifically indicated for treating this symptom.

Hyperglycemia in (option B) is incorrect: Epinephrine can potentially increase blood glucose levels, so it is not used to treat hyperglycemia.

Hand tremors in (option C) is incorrect: Epinephrine can cause tremors as a side effect, so it is not used to treat hand tremors.

A. Giving change-of-shift report to a nurse outside the client's room B. Discussing a client's prognosis with an assistive personnel who is caring for the client C. Writing a client's diagnosis on the message board in the client's room D. Discarding worksheets containing client information in a wastebasket

Correct Answer is A

Explanation

When providing a change-of-shift report, it is important to do so in a private and secure area away from public spaces. Sharing client information outside the client's room helps maintain confidentiality and prevents unauthorized individuals from overhearing sensitive information. Discussions about a client's prognosis should be limited to the appropriate healthcare professionals involved in the client's care. Sharing this information with an assistive personnel who is not directly involved in the client's care breaches confidentiality.

Displaying a client's diagnosis on a message board in a public area breaches confidentiality. It is essential to respect and protect a client's privacy by avoiding the unnecessary disclosure of sensitive information.

Proper disposal of documents containing client information is crucial to maintain confidentiality. Discarding worksheets with client information in a wastebasket without ensuring they are securely destroyed or shredded poses a risk of unauthorized access to sensitive information.

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A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is D

Explanation

A nurse is reviewing client confidentiality with other staff members. The nurse should identify that which of the following actions is an example of protecting client confidentiality?

Correct Answer is A

Explanation

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