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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Reinforce with the client to sleep on the side of the access site. B. Obtain the client's blood pressure in either arm. C. Encourage the client to increase fluid intake. D. Obtain the client's weight.

Correct Answer is D

No explanation

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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

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