Read the information below.

• Client reports pain at surgical incision site as 5 on a scale of 0 to 10.
• Client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage.
• Client transferring out of bed to chair independently.
• Extremities cool and dry with 2+ peripheral pulses.
• Client reports abdominal cramping and small, hard, painful bowel movement after lunch.
• Ambulating independently in hallway.
• Reports pain as 8 on a scale of 0 to 10, Urinary catheter intact with 100 mL/hr of pink urine.

Wearing a medical identification wristband is important for children with chronic conditions such as cystic fibrosis. It helps alert others, including healthcare providers, about the child's condition in case of emergencies. The wristband can provide vital information about the child's diagnosis, treatment needs, and emergency contacts, ensuring appropriate care and timely interventions.

The other options mentioned are not appropriate or necessary for the care of a child with cystic fibrosis:

A- It is important to involve the child to an age-appropriate extent in decision-making about their treatment. Encouraging the child to participate in their own care and treatment decisions can promote their independence and self-management skills.

B- The influenza vaccine is generally recommended for children with cystic fibrosis, as they are at increased risk of respiratory infections. The vaccine helps protect against influenza and its potential complications. Therefore, the nurse should emphasize the importance of annual influenza vaccination for the child.

D- Homeschooling may not be necessary solely based on the diagnosis of cystic fibrosis. The decision regarding the child's education should be made based on their individual needs, abilities, and preferences, in consultation with the child's healthcare team and educational professionals.

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.