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 A
Explanation
A) "I will contact the provider to let her know":
This response acknowledges the client's uncertainty about the procedure and indicates the nurse's commitment to address the client's concerns promptly by involving the healthcare provider. Contacting the provider allows for further discussion of the client's decision and consideration of any alternatives or additional information needed to support the client's choice.
B) "You should discuss your concerns with your family":
While involving family members in decision-making can be beneficial, especially for emotional support, the client's decision about the procedure is ultimately theirs to make. Encouraging discussion with family members without addressing the client's immediate concerns may not effectively address the situation.
C) "This procedure is perfectly safe":
Asserting the safety of the procedure without addressing the client's uncertainties or reasons for hesitation may not adequately address the client's concerns. It's essential to acknowledge and explore the client's apprehensions rather than dismissing them outright.
D) "Why are you changing your mind about the procedure?":
This response may come across as confrontational and may put the client on the defensive. It's important to approach the situation with empathy and support, allowing the client to express their concerns openly without feeling judged or pressured.
Correct Answer is C
Explanation
A) Vital signs flow sheet:
While vital signs are essential for assessing the client's health status, the home health agency typically focuses on the client's ongoing care needs rather than retrospective data such as vital sign trends.
B) Nursing admission assessment:
The nursing admission assessment provides valuable information about the client's initial condition upon admission to the acute care facility. However, the home health agency primarily requires information relevant to the client's current health status and ongoing care needs.
C) Current medications:
Providing the home health agency with a list of the client's current medications is essential for continuity of care. It allows the home health agency to ensure that the client receives the appropriate medications and dosages after discharge. This information helps prevent medication errors, adverse drug interactions, and omissions in the client's care plan. Additionally, the home health agency can use the medication list to reconcile medications and update the client's medication regimen as needed.
D) Nurses' notes:
While nurses' notes contain valuable information about the client's care during their stay in the acute care facility, they may not be immediately relevant to the home health agency's provision of care in the community setting. The focus of the home health agency is typically on the client's current status and needs rather than historical documentation.
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