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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Wiping yellow crusts disrupts healing; they’re normal post-Plastibell exudate. This shows misunderstanding, as crusts should remain until the ring detaches naturally.

Choice B reason: Snug diapers risk ring displacement or irritation in Plastibell care. Loose fitting is advised, so this indicates a lack of proper technique understanding.

Choice C reason: Applying pressure with gauze controls minor bleeding, a correct response in Plastibell care. It shows understanding of managing complications until medical help is sought.

Choice D reason: Antibiotic ointment isn’t routine for Plastibell; petroleum jelly is used instead. This reflects incorrect care knowledge, potentially causing irritation or infection.

A. Facial erythema B. Peeling of the hands and feet C. Fever D. Beefy, red tongue

Correct Answer is C

Explanation

Choice A reason: Facial erythema is not a hallmark of pertussis, caused by Bordetella pertussis. It may occur in scarlet fever from Streptococcus, but pertussis features paroxysmal coughing and whooping, not facial redness, making this uncharacteristic of the respiratory infection’s typical presentation.

Choice B reason: Peeling of hands and feet is typical of Kawasaki disease or scarlet fever post-streptococcal infection, not pertussis. Pertussis affects the respiratory tract, causing mucus buildup and coughing, not dermatologic desquamation, which is unrelated to its bacterial pathogenesis.

Choice C reason: Fever is expected in pertussis as the body mounts an immune response to Bordetella pertussis, elevating temperature to fight infection. Though not always high, it accompanies the catarrhal phase, reflecting systemic inflammation, a common sign in respiratory bacterial infections.

Choice D reason: Beefy, red tongue is a feature of scarlet fever or vitamin deficiencies, not pertussis. Pertussis targets the respiratory system, causing coughing and whooping, not oral mucosal changes, making this unrelated to its pathophysiology, focusing on airway irritation.

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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?

Nursing Test Bank

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