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
Tucking the glove cuffs under the gown sleeves can prevent contamination of clothing and skin by microorganisms that may be present on the gown or gloves.
The nurse should apply the gown after washing hands and before putting on gloves, and tie it securely at the neck and waist.
The nurse should not push up the gown sleeves, as this can expose skin and clothing to contamination.
Correct Answer is D
Explanation
Answer: D. I should check my heart rate while taking this medication.
Rationale: Timolol is a beta-blocker that can lower intraocular pressure by reducing aqueous humor production in the eye. However, it can also cause systemic effects such as bradycardia, hypotension, and bronchospasm. Therefore, clients should monitor their heart rate and report any signs of adverse reactions to the provider. Zinc supplements, eye dilation, and eye color changes are not associated with timolol use.
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