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

Furosemide works by promoting diuresis, which helps to reduce fluid volume overload in heart failure. Increased urinary output indicates that the medication is effectively removing excess fluid from the body. This can help alleviate symptoms such as edema and fluid retention commonly associated with heart failure. Therefore, an increased urinary output is a positive response to furosemide therapy in this context.

Decreased BUN (blood urea nitrogen) levels and weight loss are also expected outcomes of diuretic therapy, further indicating the effectiveness of the medication. However, a decreased hemoglobin level is not directly related to the efficacy of furosemide and might be indicative of other factors such as anemia or bleeding, requiring further assessment and intervention.

A. When you get better you will not feel this way. B. Why would you think a thing like that? C. What would your family do without you? D. Are you thinking of hurting yourself?

Correct Answer is D

Explanation

Are you thinking of hurting yourself?

When a client expresses thoughts of self-harm or suggests that others would be better off without them, it is essential for the nurse to assess for suicidal ideation and ensure the client's safety. Asking directly about thoughts of self-harm is an appropriate and crucial response in this situation.

When you get better you will not feel this way in (option A) is incorrect. This response minimizes the client's feelings and does not address the seriousness of the situation. It is important to assess the client's immediate safety before discussing long-term improvement.

Why would you think a thing like that? In (option B) is incorrect. This response may come across as judgmental or dismissive of the client's feelings. It is essential to provide a supportive and non- judgmental environment for the client to express their thoughts and concerns.

What would your family do without you? In (option C) is incorrect This response also minimizes the client's feelings and does not address the underlying issue. It is crucial to focus on the client's immediate safety and well-being rather than shifting the focus to the impact on others.

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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 collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

Correct Answer is D

Explanation

A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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