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 C
Explanation
A. "I'm sure your wife will begin to feel better soon."
This response is somewhat reassuring but may come across as dismissive or overly optimistic. It doesn't acknowledge the partner's feelings or offer support.
B. "It must be very difficult for you to see your wife in pain."
This response acknowledges the partner's emotions and shows empathy. While it recognizes the difficulty the partner is experiencing, it doesn't directly address the partner's desire to do something to help the wife.
C. "I wish there was more that I could do to relieve your wife's pain, too."
This response directly empathizes with the partner's wish to help the wife, expressing a shared concern. It conveys a sense of teamwork between the nurse and the partner, fostering a supportive connection.
D. "We're doing everything we can to keep your wife comfortable."
This response provides information about the actions being taken by the medical team but may not directly address the partner's expressed desire to contribute or alleviate the wife's pain.
Correct Answer is D
Explanation
A. "I will keep my walker at the end of my bed":
While keeping the walker at the end of the bed may be convenient, it is not a safety measure in itself. It's important for the client to use the walker as needed for support and stability, especially during ambulation.
B. "I will place an area rug at the entry of my bathroom":
Placing area rugs can be a fall hazard, as they may cause tripping. It is generally recommended to have non-slip surfaces, especially in areas prone to moisture like the bathroom.
C. "I will keep the fluorescent ceiling light on in my room at night":
While having adequate lighting is important for preventing falls, leaving a fluorescent ceiling light on all night may not be necessary. Using night lights or low-intensity lighting may be more appropriate to prevent disruption of sleep.
D. "I will place a bath seat in my shower to use when I bathe":
This is the correct statement. Using a bath seat in the shower provides stability and reduces the risk of slipping and falling while bathing. It is a proactive measure to enhance safety in the bathroom.
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