A nurse is conducting hourly rounds and finds a client lying on the floor in the bathroom. Which of the following actions should the nurse take first?
Assist in revising the plan of care.
Check the client for injuries.
Complete an incident report.
Notify the client's provider.
The Correct Answer is B
A. Assist in revising the plan of care: Revising the care plan is important for preventing future falls, but it is not the immediate priority. The nurse must first assess the client’s physical condition after the fall.
B. Check the client for injuries: Assessing for injuries addresses the client’s immediate safety and physical well-being, including potential fractures, head trauma, or internal injuries. This is the first action to determine the need for urgent medical intervention.
C. Complete an incident report: Documentation is essential for legal and quality improvement purposes, but it should be completed after the client’s safety and medical needs are addressed.
D. Notify the client's provider: The provider should be informed if injuries or complications are present, but notification occurs after assessing the client’s condition to provide accurate information and guidance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the client’s symptoms indicate fluid overload and pulmonary congestion. Encouraging coughing alone will not improve oxygenation or reduce pulmonary edema.
B. Increase the client's intake of oral fluids: Increasing fluids can worsen fluid overload in heart failure, exacerbating pulmonary congestion, crackles, and dyspnea. Fluid restriction may be indicated depending on the client’s status.
C. Maintain the client in high-Fowler's position: High-Fowler’s position promotes lung expansion, reduces venous return, and improves ventilation in clients with pulmonary congestion. This position helps relieve dyspnea and optimizes oxygenation, making it the priority intervention.
D. Encourage the client to ambulate to loosen secretions: Ambulation increases oxygen demand and cardiac workload, which may worsen shortness of breath and pulmonary congestion in heart failure. Activity should be limited until the client is stabilized.
Correct Answer is ["B","E","F"]
Explanation
A. Pedal pulses: Bilateral pedal pulses are documented as 2+, indicating adequate peripheral perfusion. There is no change from baseline findings on day 1. This assessment does not suggest acute circulatory compromise requiring urgent intervention.
B. Respiratory rate: An increase in respiratory rate to 24/min indicates tachypnea, which may reflect pain, infection, hypovolemia, or evolving sepsis. In the postoperative setting, this change represents physiologic stress and warrants prompt assessment. It may also signal compensation for metabolic acidosis or hypoxia.
C. Breath sounds: Breath sounds remain clear and present throughout, consistent with earlier findings. There is no evidence of atelectasis, pneumonia, or fluid overload based on this assessment. This finding does not indicate an acute deterioration.
D. Oxygen saturation: Oxygen saturation remains stable at 95% on room air, which is adequate for this client. There is no significant decline from baseline values. This parameter alone does not indicate immediate respiratory compromise.
E. Abdominal dressing: A large amount of serosanguinous drainage following a sensation of something “popping” raises concern for wound dehiscence. This is a surgical emergency that can rapidly progress to evisceration. Immediate assessment and intervention are required to prevent further complications.
F. Heart rate: A heart rate of 110/min represents tachycardia and is a significant change from baseline. This may indicate hypovolemia from blood loss, infection, or systemic inflammatory response. In combination with hypotension and fever, this finding suggests potential sepsis or hemorrhage and requires urgent follow-up.
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