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 D
Explanation
Choice A reason: Music therapy reduces pain perception but doesn’t eliminate breakthrough pain needs. Scientifically, it’s an adjunct, not a replacement, for analgesics, as severe pain signals persist despite auditory distraction, indicating misunderstanding of its supplementary role in hospice care.
Choice B reason: Discontinuing music when unresponsive overlooks its passive benefits, like comfort, even in unconscious states. Scientifically, auditory stimuli can soothe, suggesting continued use, not cessation, misaligning with hospice goals for holistic pain management.
Choice C reason: Increasing alertness contradicts music therapy’s calming effect in hospice, aimed at relaxation, not stimulation. Scientifically, it lowers arousal to ease pain perception, not heighten awareness, showing a misgrasp of its palliative intent.
Choice D reason: Music distracts from pain by engaging the brain’s auditory cortex, reducing focus on nociceptive signals. Scientifically, this aligns with gate control theory, where non-painful stimuli mitigate pain perception, reflecting accurate understanding of its role in hospice care.
Correct Answer is C
Explanation
Choice A reason: Wiping yellow crusts disrupts healing; they’re normal post-Plastibell exudate. This shows misunderstanding, as crusts should remain until the ring detaches naturally.
Choice B reason: Snug diapers risk ring displacement or irritation in Plastibell care. Loose fitting is advised, so this indicates a lack of proper technique understanding.
Choice C reason: Applying pressure with gauze controls minor bleeding, a correct response in Plastibell care. It shows understanding of managing complications until medical help is sought.
Choice D reason: Antibiotic ointment isn’t routine for Plastibell; petroleum jelly is used instead. This reflects incorrect care knowledge, potentially causing irritation or infection.
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