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 A
Explanation
Quoting client comments verbatim in the documentation should be avoided. Instead, the nurse should summarize or paraphrase the relevant information provided by the client. This helps to maintain confidentiality and professionalism in the documentation process.
Documenting giving a dose of pain medication just prior to administration: Documentation should accurately reflect the timing and administration of medications. It is not appropriate to document giving a dose of medication just prior to administering it, as it would not provide an accurate account of the client's care. The medication administration should be documented after it has been given.
Limiting documentation to subjective information: Documentation should include both objective and subjective information. Objective information refers to measurable and observable data, while subjective information represents the client's thoughts, feelings, and experiences.
Including both types of information provides a comprehensive view of the client's condition and the care provided.
Documenting information telephoned in by a nurse who left the unit for the day: Documentation should only include information that has been directly observed or obtained by the nurse providing care. It is not appropriate to document information telephoned in by a nurse who is not present and available to verify or provide additional details. Each nurse should be responsible for documenting their own observations and actions.
Accurate and comprehensive documentation is crucial for maintaining continuity of care, ensuring effective communication among the healthcare team, and promoting the client's safety and well-being. Nurses should adhere to institutional policies and guidelines regarding documentation practices and prioritize accuracy, confidentiality, and professionalism in their documentation.
Correct Answer is ["C","D","F","H"]
Explanation
a. Heart rate: The heart rate of 98/min is within normal limits and does not indicate an immediate need for further evaluation based solely on this value.
b.The blood pressure of 112/88 mmHg is within normal limits and does not indicate an immediate need for further evaluation based solely on this value.
c.The client has a temperature of 38.1°C (100.5°F), which is indicative of a fever. Fever, especially when associated with other symptoms such as cough, fatigue, night sweats, and weight loss, suggests a systemic infection or inflammatory process requiring further investigation.
d.The client reports a cough that is often productive and blood-tinged sputum. Respiratory complaints with blood-tinged sputum can indicate potential serious conditions such as pneumonia, tuberculosis, or other respiratory infections that require prompt evaluation and treatment.
e.The pulse oximetry reading of 98% on room air is normal and does not indicate an immediate need for further evaluation based solely on this value.
f.The client reports a recent weight loss of 2.26 kg (5 lb) over the past week, along with decreased appetite. Unintentional weight loss, especially when associated with other symptoms like fever and cough, raises concerns about underlying systemic illness or malignancy that requires further investigation.
g.Blood in sputum can have various causes and needs investigation.
h.Recent travel can increase exposure to different illnesses, so it's relevant and needs further evaluation.
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