A nurse is assisting with staff education about hand hygiene.

Which of the following instructions should the nurse include in the teaching?

Levothyroxine is a medication used to treat hypothyroidism, and monitoring the TSH levels helps determine the effectiveness of the medication.

Blood urea nitrogen (BUN) is a test used to assess kidney function and is not specifically related to thyroid function or levothyroxine therapy.

Prothrombin time (PT) is a test used to evaluate the clotting ability of the blood and is not directly related to thyroid function or levothyroxine therapy.

Arterial blood gases (ABGs) are used to assess oxygen and carbon dioxide levels in the blood and evaluate acid-base balance. ABGs are not specifically related to thyroid function or levothyroxine therapy.

When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.

The other options listed are also important but should be addressed after the initial assessment and safety measures:

1. Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
2. Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
3. Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.