A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

A) Notify the nurse manager:

While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.

B) Check the family member's vital signs:

The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.

C) Obtain the family member's health history:

Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.

D) Complete an incident report:

Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.

A) I will take chemotherapy since my family wants me to:

This statement indicates a potential lack of autonomy and decision-making by the client. The nurse should act as a client advocate by ensuring that the client's decisions regarding treatment are based on their own wishes, values, and preferences, rather than solely on the desires of others.

B) I will discuss treatment options next week after thinking about this:

This statement demonstrates the client's intent to participate in the decision-making process regarding their treatment options. While it indicates autonomy and contemplation, it does not necessarily require the nurse to act as a client advocate at this time.

C) I do not want to have any surgery for my cancer:

This statement reflects the client's autonomy and preference regarding their treatment plan. While the nurse should respect the client's decision, it does not directly prompt the nurse to act as a client advocate.

D) I have contacted another surgeon to get a second opinion:

This statement shows the client's proactive approach to gathering additional information about their treatment options, which is commendable. However, it does not specifically indicate a need for the nurse to advocate for the client's rights or preferences.