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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Let me show you how to swaddle and cuddle him, then you try.

The appropriate response for the nurse in this situation is to provide support and education to the new mother. Option B, "Let me show you how to swaddle and cuddle him, then you try," demonstrates a helpful and empowering approach.

I'll take him back to the nursery, so you can get some rest in (option A) is incorrect. This response dismisses the mother's concerns and suggests removing the baby from her care without addressing her need for guidance and support. It is important to encourage and assist the mother in learning how to care for her newborn rather than taking over the responsibility.

If I turn him on his side, maybe he'll go back to sleep in (option C) is incorrect. This response suggests a specific action without addressing the underlying concerns of the mother. It is important to provide guidance and reassurance rather than suggesting potential solutions without understanding the cause of the baby's crying.

Babies need to cry soon after they are born to develop their lungs in (option D) is incorrect. This response is not relevant to the mother's concerns and does not address her feelings of inadequacy. It is important to provide support and guidance in caring for the newborn rather than providing unrelated information.

A. "I can have two glasses of wine with dinner." B. "I will set my blood pressure goal at 130 over 84. C. "I should decrease my salt intake to 2 grams per day." D. "I should exercise for 15 minutes two times per week."

Correct Answer is C

Explanation

"I should decrease my salt intake to 2 grams per day." - This statement is correct. Decreasing salt intake is an important dietary modification for individuals with hypertension. The general recommendation is to limit sodium intake to 2 grams per day or less. Reducing salt intake can help lower blood pressure levels.

"I can have two glasses of wine with dinner." - This statement is not accurate. While moderate alcohol consumption may have some health benefits, it is generally recommended to limit alcohol intake, especially for individuals with hypertension. The specific recommendation for alcohol consumption may vary depending on individual factors and should be discussed with a healthcare provider.

"I will set my blood pressure goal at 130 over 84." - This statement is not accurate. The blood pressure goal for individuals with hypertension is generally set at 130 over 80 or lower. It is important for the client to work with their healthcare provider to determine an appropriate blood pressure goal based on their specific situation.

"I should exercise for 15 minutes two times per week." - This statement is not accurate. While any amount of physical activity is beneficial, the current recommendations for adults include at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities on two or more days. The client should aim for a higher frequency and duration of exercise to achieve optimal health benefits.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is preparing to administer tetanus and diphtheria toxoids (Td) to a client. What technique the nurse should plan to use?

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?

A nurse in an acute care setting is preparing to administer medications to a client. Which of the following information should the nurse obtain to identify the client?