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 A

Explanation

To calculate the percentage of weight loss, we can use the formula:

Percentage of weight loss = (Weight loss / Original weight) * 100

Given that the client lost 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb), we can substitute these values into the formula:

Percentage of weight loss = (6.8 kg / 90.7 kg) * 100 Percentage of weight loss = 0.0749 * 100 Percentage of weight loss = 7.49%

The percentage of weight loss is approximately 7.49%.

Since none of the provided answer options exactly match this calculated percentage, the closest option is:

So, the nurse should identify the weight loss as approximately 7.5%.

A. Instruct the family to leave prior to cleaning the client's body. B. Encourage the family to express their feelings of loss. C. Limit the amount of time the family spends in the client's room. D. Ask the family not to touch the client's body.

Correct Answer is B

Explanation

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.

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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 discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is A

Explanation

A nurse caring for the family of a client who recently died. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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