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 D
Explanation
A) Send the client for the test with the unsigned form:
This option is not appropriate because performing an invasive procedure without obtaining informed consent from the client violates ethical and legal principles. Proceeding without proper consent could lead to legal and ethical repercussions, and it is not considered a safe or acceptable practice.
B) Wake the client and ask them to sign the form:
Waking the client who has received a sedative to obtain their signature on the consent form is not advisable. The client may still be under the influence of the sedative, which could impair their ability to understand the information provided and make an informed decision. Additionally, obtaining consent in this manner may not be legally valid and could compromise the client's autonomy and rights.
C) Obtain consent from a family member:
While obtaining consent from a family member might seem like a reasonable option, it is not appropriate in this scenario without clear documentation of the client's inability to provide consent. Consent for medical procedures should ideally be obtained directly from the competent adult client unless they are incapacitated or unable to make decisions. In this case, the client is asleep due to the sedative, but there is no indication that they are incapable of providing consent. Therefore, relying on a family member's consent without attempting to obtain it from the client first may not be ethically or legally justified.
D) Inform the charge nurse:
This is the most appropriate action to take initially. Informing the charge nurse allows for consultation and guidance on how to proceed in this situation. The charge nurse may advise on the appropriate steps to follow, such as contacting the provider or waiting for the client to regain consciousness to obtain informed consent. It ensures that the situation is addressed promptly and in accordance with institutional policies and ethical standards.
Correct Answer is D
Explanation
A) Turn off electrical equipment in the client's room: While turning off electrical equipment can help prevent the spread of fire if the source is electrical, it may not be the most immediate action to take after removing the client from the room. The priority is to activate the alarm to alert others and initiate the fire response protocol.
B) Use a Class A fire extinguisher to contain the fire: Using a fire extinguisher is a potential action, but the type of fire extinguisher needed depends on the type of fire. Class A fire extinguishers are suitable for ordinary combustibles such as wood and paper. However, since the source of the fire is a trash can, the fire may involve combustible materials beyond Class A. Therefore, activating the alarm takes precedence over extinguishing the fire.
C) Close the door to the client's room: Closing the door can help contain the fire and prevent its spread to other areas. While this action is important, it is secondary to activating the alarm, which alerts others to the fire and initiates the response process.
D) Activate the alarm outside the client's room: This is the most appropriate action to take first. Activating the alarm alerts others to the fire, enabling them to respond promptly and effectively. It initiates the facility's fire response protocol, including evacuating occupants and summoning the fire department. This action ensures the safety of everyone in the vicinity and allows for a coordinated emergency response.
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