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.
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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 ["A","B","C","D"]
Explanation
A. Instruct the clients to use the call light.
Encouraging clients to use the call light enables them to request assistance when needed, reducing the risk of falls if they need help to move or get out of bed.
B. Move overbed tables away from the bed.
Clearing the area around the bed, including overbed tables, reduces obstacles and potential hazards that clients might trip over or get tangled in.
C. Place a fall risk wristband on each of the clients.
Identifying clients at risk for falls by using wristbands helps alert all healthcare staff to take necessary precautions and provide appropriate assistance to prevent falls.
D. Perform client checks every 4 hr.
Regular client checks allow the nurse to monitor their condition, reposition them if necessary, assist with toileting needs, and ensure they're safe, especially during the night when falls might be more likely.
E. Keep the clients' rooms dark.
Keeping the room dimly lit during the night can help clients sleep better but should still provide enough light for safe movement. Complete darkness might increase the risk of falls if clients need to move around.
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