A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
Notify the client's provider.
Measure the client's vital signs.
Complete an incident report.
Document the fall in the client's medical record.
The Correct Answer is B
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:
A. 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.
C. 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.
D. 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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Do you have any plan for harming yourself?
When a client expresses suicidal ideations, the nurse's priority is to assess whether the client has a specific plan for harming themselves. This question helps determine the level of immediate risk and guides the nurse's actions in providing appropriate interventions and ensuring the client's safety.:
Can you tell me about the stresses in your life? In (option B) is incorrect. While understanding the client's stressors is important in assessing their overall mental health, it may not be the priority question in this situation. The immediate concern is to assess the presence of a specific plan for self-harm.
Do you have someone to discuss your feelings with? In (option C) is incorrect. Having someone to talk to about feelings can be beneficial for the client, but it is not the priority question in this situation. The primary focus is to assess the client's immediate risk and take appropriate actions to ensure their safety.
Has anyone in your family ever died by suicide? In (option D) is incorrect. Family history of suicide can be a risk factor for suicidal ideation, but it is not the priority question in this scenario. Assessing the client's current risk and immediate plan for self-harm is more crucial to determine the necessary interventions.
Correct Answer is A
Explanation
This statement reflects an important recommendation for car seat safety. It is recommended to keep infants and toddlers rear-facing in their car seats until they reach the age of 2 or until they outgrow the height and weight limits specified by the car seat manufacturer. Rear-facing car seats provide better protection for the child's head, neck, and spine in the event of a crash.
"I should position the car seat's retainer clip at the level of my baby's belly button." The correct position for the retainer clip is at the armpit level. It should be positioned across the chest, resting on the bony part of the child's shoulders. Placing the retainer clip at the level of the belly button can be unsafe and may not provide proper protection.
"I should enable the airbag when my baby is in the front seat of the car." It is not recommended to place a rear-facing car seat in the front seat of a vehicle with an active airbag. The force of the airbag deployment can cause serious injuries to the child. The safest place for a rear-facing car seat is in the back seat of the vehicle.
"I should place my baby in the car seat at a 90-degree angle." The angle at which the car seat is installed depends on the specific instructions provided by the car seat manufacturer. It is important to follow the manufacturer's guidelines for proper installation. Some car seats have built-in angle indicators or adjustable recline positions to help achieve the correct angle for optimal safety.
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