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 B
Explanation
A. Concurrent treatment for GERD:
This is not typically a contraindication for hormone replacement therapy (HRT). GERD treatment is not directly related to the decision to use HRT.
B. History of breast cancer:
This is a contraindication for HRT. Estrogen replacement therapy has been associated with an increased risk of breast cancer. Therefore, individuals with a history of breast cancer are generally advised against using HRT.
C. History of dermatitis:
A history of dermatitis is not a contraindication for HRT. However, the decision to use HRT should be made based on a comprehensive assessment of the client's overall health and risk factors.
D. Multiple hospitalizations for COPD:
While COPD itself is not a contraindication for HRT, decisions about HRT should consider the individual's overall health status and potential risks. Factors such as smoking history and respiratory function may be considered in the assessment.
Correct Answer is C
Explanation
A. Provide support by holding the client's arm:
While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.
B. Maintain a narrow base of support:
Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.
C. Lower the client to the floor:
This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.
D. Lean the client toward the wall:
Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.
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