A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?
Obtain the client's vital signs.
Inform the client's family member.
Notify the client's provider.
Assist the client back into bed.
The Correct Answer is A
A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signs provides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.
B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.
C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.
D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To administer lorazepam 1 mg PO to an older adult client who has insomnia and who cannot swallow oral tablets, the nurse should use the lorazepam oral solution 2 mg/mL.
The nurse should calculate the dose by using the formula: Dose (mL) = Desired dose (mg) / Available dose (mg/mL).
In this case, the desired dose is 1 mg and the available dose is 2 mg/mL.
Therefore, the dose (mL) = 1 mg / 2 mg/mL = 0.5 mL.
The nurse should plan to administer 0.5 mL of lorazepam oral solution to the client.
Correct Answer is D
Explanation
A. Provide client care as assigned:
While it is essential to be flexible and adaptable, patient safety is a priority. If the nurse is not familiar with certain skills or techniques and believes it could compromise patient safety, blindly providing care may not be the best option.
B. Make a formal complaint to the nursing manager:
Making a formal complaint should not be the initial step. It is better to explore other options before escalating the situation to a higher level.
C. Request the charge nurse to modify the assignment:
This is a reasonable option. The nurse can communicate concerns to the charge nurse and request modifications to the assignment based on their skills and competency.
D. Ask another nurse to trade assignments:
This is the most immediate and practical solution. If there's another nurse available who is more familiar with the required skills, trading assignments can ensure that the patient receives appropriate care from a nurse with the necessary expertise.
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