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.
Document the fall in the client's medical record.
Complete an incident report.
The Correct Answer is B
Choice A reason: Notifying the provider follows assessment; vital signs gauge injury first. Immediate stability check precedes communication in a fall scenario like this.
Choice B reason: Measuring vital signs first assesses for shock, injury, or distress post-fall. It’s the priority to ensure safety before further actions in emergencies.
Choice C reason: Documentation is essential but secondary to client stability. Vital signs determine urgency, so recording waits until immediate health risks are evaluated.
Choice D reason: Incident reports address safety trends, not acute care. Assessing vital signs first ensures the client’s condition guides subsequent reporting and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.
Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.
Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.
Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.
Correct Answer is C
Explanation
Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.
Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.
Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.
Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.
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