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?
Complete an incident report.
Notify the client's provider.
Document the fall in the client's medical record.
Measure the client's vital signs.
The Correct Answer is D
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. "Fidelity involves keeping promises made to clients." The rationale for this statement is that fidelity is a principle of ethics that requires nurses to be faithful, loyal, and trustworthy to their clients. Fidelity means that nurses should honor their commitments and obligations to their clients, such as following through with care plans, respecting confidentiality, and being honest. Fidelity also implies that nurses should advocate for their client's best interests and protect them from harm.
Correct Answer is D
Explanation
Answer: D. Elevated lipase
Rationale: Pancreatitis is an inflammation of the pancreas that causes pancreatic enzymes to leak into the bloodstream and damage surrounding tissues. Lipase is one of these enzymes that is produced by the pancreas to digest fats. An elevated lipase level indicates pancreatic injury and is a diagnostic marker for acute pancreatitis. The other laboratory results are not specific to pancreatitis and could be caused by other conditions.
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