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?
Complete an incident report.
Notify the client's provider.
Document the fall in the client's medical record.
Measure the client's vital signs.
The Correct Answer is D
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Correct Answer is C
Explanation
The correct answer is C. Observe the client during and after meals. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The nurse should monitor the client for signs of purging, such as frequent trips to the bathroom, and provide support and supervision during and after meals to prevent this behavior . This is a priority intervention that addresses the client's physical health and safety.
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