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.
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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Related Questions
Correct Answer is D
Explanation
range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.
Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.
Correct Answer is B
Explanation
Determine the acuity and number of casualties arriving at the facility
During a mass casualty event, the nurse working on a medical-surgical unit can anticipate being assigned the task of determining the acuity and number of casualties arriving at the healthcare facility. This involves assessing the severity of injuries and prioritizing care based on the level of urgency. The nurse will be responsible for triaging and assigning appropriate resources to each patient based on their condition.
Provide informational updates to members of the media. In (option A) is incorrect. While communication and coordination with the media may be necessary during a mass casualty event, this is typically handled by designated spokespersons or hospital administration. Nurses are primarily focused on providing direct patient care and managing the influx of patients.
Assist in discharging stable clients to home in (option C) is incorrect. During a mass casualty event, the focus is on providing care to the injured and managing the influx of casualties. Discharging stable clients to home would not be a priority task during such an event.
Delegate tasks to emergency healthcare specialists in (option D) is incorrect. Nurses may collaborate with emergency healthcare specialists during a mass casualty event, but they usually take on leadership roles in coordinating and providing direct care. Nurses are responsible for assigning tasks and coordinating the efforts of the healthcare team, including specialists, to ensure effective care delivery.
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