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 B
Explanation
The correct answer is choice B. Nontender, protruding abdomen.
Choice A rationale:
Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.
Choice B rationale:
A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.
Choice C rationale:
By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.
Choice D rationale:
Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.
Correct Answer is B
Explanation
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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