A client begins to fall while the nurse is assisting with ambulation. What is the priority nursing intervention?
Initiate a code.
Call the charge nurse.
Guide the client safely to the floor.
Call the client's doctor.
The Correct Answer is C
The priority nursing intervention when a client begins to fall while ambulating is to guide the client safely to the floor.
This can help prevent injury and ensure the safety of the client.
CHOICE A. Initiating a code is not necessary for this situation as it is not a medical emergency.
CHOICE B AND D : Calling the charge nurse or the client’s doctor may be appropriate after the client has been safely guided to the floor and their condition has been assessed
[B] [D].
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Related Questions
Correct Answer is D
Explanation
The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.
Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.
Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.
Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.
Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.
Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.
Correct Answer is C
Explanation
The primary purpose of an incident report is to identify opportunities for improvement.
Incident reports are used to document and analyze events that have occurred in order to identify areas for improvement and prevent similar incidents from happening in the future.
Choice A is not an answer because incident reports are not typically used as a tool for disciplinary action.
Choice B is not an answer because while incident reports can help identify and address errors, their primary purpose is not to eliminate unforeseen errors.
Choice D is not an answer because the primary purpose of incident reports is not to hold persons accountable for their errors, but rather to identify opportunities for improvement.
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