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 D
Explanation
A. Aspirin is not primarily prescribed to prevent fever. Its primary mechanism of action is related to its effects on platelets and blood clotting rather than its antipyretic (fever-reducing) properties.
B. While aspirin can provide analgesic (pain-relieving) effects, especially for mild to moderate pain, its use in clients with coronary artery disease is primarily due to its antiplatelet properties rather than its analgesic effects.
C. Aspirin has some anti-inflammatory properties, but in the context of coronary artery disease, its main benefit is related to its antiplatelet function rather than its anti-inflammatory effects.
D. Aspirin is widely prescribed in cardiovascular conditions like coronary artery disease because it inhibits the aggregation of platelets, reducing the risk of blood clot formation. This antiplatelet effect helps in preventing blood clots that could potentially lead to further blockages in the arteries, reducing the risk of complications such as heart attacks or strokes in individuals with heart disease.
Correct Answer is B
Explanation
A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.
C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.
D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.