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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Fidelity is keeping promises and maintaining trust, as the nurse commits to walking daily with the client. This builds therapeutic reliability, reducing anxiety through consistent support, aligning with ethical standards where honoring commitments fosters psychological safety and strengthens the nurse-patient relationship scientifically.
Choice B reason: Justice involves fair resource distribution, not individual promises like walking with a client. This scenario focuses on personal commitment, not equity among patients. Ethically, justice applies to systemic fairness, lacking relevance to this specific supportive action grounded in trust-building principles.
Choice C reason: Nonmaleficence means avoiding harm, but promising to walk exceeds mere harm prevention, aiming to alleviate anxiety actively. While it supports well-being, it’s not the primary principle here. Scientifically, this is more about trust than just safety, distinguishing it from nonmaleficence’s core intent.
Choice D reason: Autonomy respects client decisions, but the nurse’s promise is her initiative, not the client’s choice. It supports, not directs, independence. Ethically, autonomy focuses on self-determination, whereas this action reflects commitment, making fidelity the more fitting principle in this scenario.
Correct Answer is B
Explanation
Choice A reason: Budesonide prevents, not rescues, asthma attacks; rescue inhalers like albuterol are used instead. This shows misunderstanding of its controller role in management.
Choice B reason: Rinsing after budesonide, a corticosteroid, prevents oral thrush by removing residue. This reflects correct understanding of side effect prevention in asthma therapy.
Choice C reason: Timing budesonide to meals and bedtime isn’t standard; it’s typically twice daily. This indicates confusion about its preventive, not situational, use.
Choice D reason: Pre-exercise use fits rescue inhalers, not budesonide, which builds long-term control. This misapplies its purpose, showing a lack of asthma management grasp.
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