A nurse enters a client’s room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
Notify the client's provider.
Measure the client's vital signs.
Document the fall in the client's medical record.
Complete an incident report.
The Correct Answer is B
Choice A reason: Notifying the provider follows assessment; vital signs gauge injury first. Immediate stability check precedes communication in a fall scenario like this.
Choice B reason: Measuring vital signs first assesses for shock, injury, or distress post-fall. It’s the priority to ensure safety before further actions in emergencies.
Choice C reason: Documentation is essential but secondary to client stability. Vital signs determine urgency, so recording waits until immediate health risks are evaluated.
Choice D reason: Incident reports address safety trends, not acute care. Assessing vital signs first ensures the client’s condition guides subsequent reporting and intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An NG tube is for feeding or decompression, not seizure management. Seizures may cause vomiting, but NG tubes aren’t standard bedside tools for this. They address nutritional needs, not airway protection, making them irrelevant to immediate seizure safety protocols based on clinical evidence.
Choice B reason: A suction machine clears secretions or vomit during a seizure, preventing aspiration—a key risk as airway control is lost. This aligns with scientific priority on airway management, making it essential bedside equipment for seizure patients to ensure respiratory safety during convulsive episodes.
Choice C reason: Lorazepam treats prolonged seizures, but pre-filled syringes aren’t typically bedside; they’re in emergency kits. It’s a pharmacological intervention, not a standard immediate tool, and requires physician orders, making it less practical than suction for routine seizure readiness per evidence-based practice.
Choice D reason: Tongue blades are outdated for seizures; forcing them in risks tooth damage or aspiration. Modern guidelines prioritize airway protection via positioning or suction, not oral insertion, as seizures don’t typically cause tongue swallowing, debunking this as a scientifically supported bedside necessity.
Correct Answer is B
Explanation
Choice A reason: Explaining pros and cons informs but may pressure the client. Supporting autonomy respects their choice, aligning with lung cancer end-of-life preferences better.
Choice B reason: Supporting the client’s DNR decision upholds autonomy and aids communication. In lung cancer, respecting end-of-life wishes is critical, making this the best response.
Choice C reason: Involving a social worker delegates support, not directly honoring the client’s wish. Nurses should first affirm autonomy in such terminal cancer scenarios.
Choice D reason: Suggesting family discussion undermines autonomy, adding burden. The client’s decision in advanced cancer should be respected without implying external validation needs.
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