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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Related Questions
Correct Answer is ["B","C"]
Explanation
The client received the prescribed antibiotic every 8 hours: This is important information as it relates to the client's medication administration and treatment plan. It allows the incoming nurse to be aware of the medication schedule and ensure continuity of care.
The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client.
The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.
While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.
In summary, the nurse should include information that is pertinent to the client's immediate care needs and current condition. This includes medication administration, pain management preferences, changes in condition, or any relevant information that may impact the client's care plan.
Correct Answer is C
Explanation
Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect the skin. Proper skin care is important for individuals with SLE to minimize potential flare-ups or exacerbation of skin symptoms. The recommended approach to skin care in SLE includes gentle cleansing and moisturizing.
"I will use an astringent on my face." Astringents are typically not recommended for individuals with SLE as they can be harsh on the skin and may cause irritation or dryness.
"I will cleanse my skin using an antibacterial soap." While it is important to keep the skin clean, using an antibacterial soap is not specifically required for individuals with SLE. Gentle,
Non-irritating cleansers without antibacterial properties are generally recommended.
"I will limit my time in the tanning bed to 15 minutes." Exposure to ultraviolet (UV) radiation, such as from tanning beds, can be particularly harmful to individuals with SLE. UV radiation can trigger or worsen skin manifestations and may lead to disease flares. Therefore, it is generally advised for individuals with SLE to avoid tanning beds altogether.
In addition to gentle cleansing and moisturizing, individuals with SLE should also practice sun protection, including wearing sunscreen with a high sun protection factor (SPF) and using protective clothing and accessories (such as hats and sunglasses) when exposed to the sun. Regular check-ups with a healthcare provider and following their recommendations are important for managing SLE and its associated skin manifestations.
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