A nurse is admitting a client for an elective surgical procedure. During the client interview. one of the client's family members faints. Which of the following actions should the nurse take first?
Notify the nurse manager.
Check the family member's vital signs.
Obtain the family member's health history.
Complete an incident report.
The Correct Answer is B
A) Notify the nurse manager:
While it's essential to involve the nurse manager in situations involving unexpected events or emergencies, the immediate priority is to assess the well-being of the fainting family member. Notifying the nurse manager can be done after ensuring the family member's immediate needs are addressed.
B) Check the family member's vital signs:
The first action the nurse should take is to assess the fainting family member's vital signs to determine their current physiological status. Checking vital signs can provide crucial information about the person's condition and guide further actions. This assessment helps ensure the family member's safety and well-being.
C) Obtain the family member's health history:
Obtaining the family member's health history is important for understanding any underlying medical conditions that may have contributed to the fainting episode. However, assessing vital signs takes precedence to address any immediate medical concerns related to the fainting episode.
D) Complete an incident report:
Completing an incident report is necessary to document the fainting episode for organizational records and quality improvement purposes. However, this task can be completed after addressing the immediate needs of the fainting family member and ensuring their safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
Correct Answer is C
Explanation
A) A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective:
This scenario does not represent slander. While discussing the possibility of using restraints with a client's health care surrogate involves sensitive communication, it does not constitute slander. The nurse is providing information about potential interventions based on the client's needs and safety concerns, which is a part of the nursing role.
B) A nurse documents that a client was shouting and directly quotes the client's words:
This scenario involves accurate documentation of a client's behavior and does not constitute slander. Documenting a client's actions, such as shouting, with direct quotes from the client's words is essential for providing an accurate record of events and communication during the client's care.
C) A client overhears assistive personnel make a false statement about the assigned nurse and requests a different nurse:
This scenario represents slander. Slander involves making false statements that harm someone's reputation, and in this case, the assistive personnel's false statement about the assigned nurse could damage the nurse's professional reputation. The client's request for a different nurse indicates the potential negative impact of the false statement on the nurse's relationship with the client.
D) A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired:
This scenario involves reporting a concern about a coworker's potential impairment, which is not an example of slander. Reporting concerns about impairment is a critical aspect of ensuring patient safety and maintaining professional standards in healthcare settings. However, such reports should be handled confidentially and with appropriate discretion.
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