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: Dark red urine signals active bleeding post-TURP, beyond expected light pink. It may indicate hemorrhage, requiring urgent provider intervention to prevent complications.
Choice B reason: 300 mL over 8 hr is adequate output post-TURP, not alarming. It aligns with expected bladder irrigation effects, needing no immediate report.
Choice C reason: Small clots are normal post-TURP as the prostate heals. Only large or persistent clots warrant concern, so this is an expected finding.
Choice D reason: Frequent urination urge is common post-TURP from bladder irritation. It’s not critical unless paired with obstruction, so it doesn’t need reporting.
Correct Answer is B
Explanation
Choice A reason: Massaging a DVT risks dislodging the clot, causing embolism. In postpartum with anticoagulants, this is contraindicated to prevent lethal complications.
Choice B reason: Bed rest minimizes clot movement in DVT, aiding anticoagulation postpartum. It reduces embolism risk, a critical safety measure in this scenario.
Choice C reason: Ice may reduce swelling, but it’s not standard for DVT with anticoagulants. Elevation and rest are prioritized over cold therapy here.
Choice D reason: Aspirin isn’t used with anticoagulants like heparin; it increases bleeding risk. Postpartum DVT needs specific pain management, not this drug.
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