A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Inform the client's family member.

Notify the client's provider.

Assist the client back into bed.

Answer and Explanation

The Correct Answer is A

A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signs provides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.

B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.

C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.

D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.

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Correct Answer is D

Explanation

A. "Unlike an x-ray, the MRI allows you to move around a bit":

This statement is not accurate. During an MRI, it is important for the client to remain as still as possible to obtain clear images. Movement can result in blurred images.

B. "Your exposure to radiation will be minimal":

This statement is not applicable to MRI, as MRI does not use ionizing radiation. It uses a strong magnetic field and radio waves to generate images, making it different from x-rays in terms of radiation exposure.

C. "You will not be able to talk to the technician during the procedure":

While it is essential for the client to remain still during an MRI, communication with the technician is generally possible through an intercom system. The client may be given instructions and reassurance during the procedure.

D. "You'll have to remove metal objects such as watches and body jewelry":

This is the correct statement. Metal objects can interfere with the magnetic field used in MRI and can pose a safety risk. Therefore, clients are required to remove any metal objects before undergoing an MRI.

A. "I need to talk to you about unit expectations regarding timely completion of tasks." B. "You have been very inconsiderate of others by not completing your share of the work." C. "Several staff members have commented that you don't do your fair share of the work." D. "If you don't do your share of the work, I will have to inform the nurse manager."

Correct Answer is A

Explanation

A. "I need to talk to you about unit expectations regarding timely completion of tasks."

This statement is non-confrontational and focuses on discussing the expectations of the unit regarding task completion. It allows the nurse to address the specific behavior (taking long breaks and making personal phone calls) without making accusatory or negative statements.

B. "You have been very inconsiderate of others by not completing your share of the work."

This statement may be perceived as accusatory and could escalate the conflict. It is important to communicate concerns without placing blame.

C. "Several staff members have commented that you don't do your fair share of the work."

This statement involves bringing in third-party opinions, which may not be the most direct and effective way to address the issue. It's better to address the concern directly with the individual involved.

D. "If you don't do your share of the work, I will have to inform the nurse manager."

Threatening to inform the nurse manager without first addressing the issue through communication can escalate the conflict. It's generally more productive to attempt to resolve conflicts through open and direct communication before involving higher authorities.

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A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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