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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is C.

Using the continuous passive-motion machine intermittently helps to prevent joint stiffness and promote circulation in the surgical leg. Applying warm, moist packs to the surgical site can increase inflammation and infection risk. Placing a pillow under the client's surgical knee can cause flexion contractures and impair healing. Massaging the lower leg in smooth, long strokes can dislodge a thrombus and cause a pulmonary embolism.

A. Ensure that the client's family supports the provider's decision for surgery. B. Send the unsigned informed consent form to the facility's risk manager. C. Determine if the procedure is medically necessary for the client. D. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.

Correct Answer is D

Explanation

Choice A reason

Ensuring that the client's family supports the provider's decision for surgery is not an appropriate action. While family support is essential in the decision-making process, the primary responsibility lies with the client's health care surrogate or designated decision-maker. The family's support is not a substitute for obtaining informed consent from the designated decision-maker.

Choice B reason

Sending the unsigned informed consent form to the facility's risk manager is not appropriate action. The nurse should not send an unsigned informed consent form to the facility's risk manager. Unsigned consent forms do not have any legal significance or validity. The nurse should work with the health care surrogate to ensure that the consent form is appropriately completed and signed.

Choice C reason

Determining if the procedure is medically necessary for the client is not appropriate action. While the medical necessity of the procedure is important, the decision about the procedure's necessity should be made by the medical team and discussed with the health care surrogate. The nurse's role is to facilitate communication and ensure that the surrogate is informed and involved in the decision-making process.

Choice D reason

When a client is in a coma and unable to provide informed consent, the health care surrogate or designated decision-maker becomes responsible for making medical decisions on behalf of the client. It is essential for the nurse to ensure that the health care surrogate is aware of the situation, understands the risks and benefits of the surgical procedure, and has provided informed consent on behalf of the client.

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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

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Correct Answer is C

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Correct Answer is D

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