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 D
Explanation
Choice A reason: Meningococcal vaccine starts at 11-12 years, not infancy; three doses by kindergarten is incorrect. Scientifically, this misaligns with CDC schedules, as 2-month-olds get other vaccines (e.g., DTaP), showing misunderstanding of immunization timing.
Choice B reason: No feeding restriction exists for immunizations; fasting isn’t required. Scientifically, nutrition supports immune response, and this contradicts standard practice, as feeding doesn’t affect vaccine efficacy or safety, indicating a preparation misconception.
Choice C reason: High fever for 24 hours isn’t typical; mild fever may occur but not guaranteed. Scientifically, this exaggerates normal vaccine reactions (e.g., low-grade fever), misrepresenting expected immune responses, suggesting inaccurate outcome expectations.
Choice D reason: Rotavirus vaccine is oral at 2 months, per CDC schedule, aligning with its live attenuated form. Scientifically, this reflects correct administration knowledge, as it targets gut immunity, showing the guardian understands this immunization’s delivery accurately.
Correct Answer is D
Explanation
Choice A reason: Sims’ position is for rectal exams, not central catheter insertion. Trendelenburg or supine is used, so this is incorrect for TPN prep.
Choice B reason: Verifying TPN amount is ongoing care, not insertion prep. Initial placement confirmation via x-ray takes precedence over infusion monitoring here.
Choice C reason: Clean technique risks infection in central lines; sterile is required. This compromises TPN safety, making it an incorrect preparatory step.
Choice D reason: Chest x-ray confirms catheter tip placement in the vena cava for TPN. It’s a critical prep step to ensure safe administration begins.
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