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?

Complete an incident report.

Notify the nurse manager.

Obtain the family member's health history.

Check the family member's vital signs.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Completing an incident report is important for documentation and accountability but does not address the immediate issue of a fainting family member. Ensuring the family member's safety takes precedence in this scenario.

Choice B rationale

Notifying the nurse manager is necessary for communication, but it is not the first action. Prioritizing assessment ensures any critical issues are promptly addressed to stabilize the family member's condition.

Choice C rationale

Obtaining the family member’s health history could provide context for the fainting episode but delays immediate assessment. Addressing acute concerns like airway, breathing, and circulation is crucial before obtaining history.

Choice D rationale

Checking vital signs is a priority as it provides immediate information about the family member’s condition. Assessment of blood pressure, heart rate, and oxygen saturation helps identify underlying causes such as hypotension, arrhythmia, or hypoxia for appropriate intervention.

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Correct Answer is A

Explanation

Choice A rationale

Closing the door prevents the spread of smoke and fire to other areas, protecting clients and staff. This action aligns with the RACE (Rescue, Alarm, Contain, Extinguish) protocol to contain fire hazards effectively while prioritizing safety.

Choice B rationale

Reporting fire details is crucial but should occur after ensuring client safety and containment of the fire. Early containment by closing the door prevents escalation, reducing the risk of harm to others in the facility.

Choice C rationale

Activating the fire alarm is important; however, containment actions such as closing the door take precedence to manage the immediate fire hazard. Containment minimizes risks while allowing subsequent emergency actions to occur.

Choice D rationale

Turning off electrical equipment is important but secondary in prioritization. Containing the fire’s spread by closing the door first ensures broader safety for all. Electrical disconnection can follow once the immediate hazard is managed.

A. Apply wrist restraints to the client. B. Engage the client in a repetitive activity as a distraction. C. Place the client in a seclusion room. D. Administer PRN haloperidol IM to the client.

Correct Answer is B

Explanation

Choice A rationale

Applying wrist restraints immediately is an invasive intervention that may escalate the client’s agitation and anger. Restraints are used when absolutely necessary to prevent harm, and only after other de-escalation techniques have failed. Their use may breach the least restrictive intervention principle, which prioritizes non-invasive measures first.

Choice B rationale

Engaging the client in a repetitive activity acts as a distraction and can reduce agitation by refocusing their attention. This technique aligns with dementia care principles, emphasizing non-pharmacological interventions to manage behavioral disturbances. By promoting sensory engagement, it can help mitigate aggression effectively and respectfully.

Choice C rationale

Placing the client in a seclusion room can escalate feelings of confusion, isolation, and fear, worsening agitation. Seclusion should only be a last resort for safety reasons and not a first-line intervention in dementia care. It is contraindicated unless immediate harm is likely.

Choice D rationale

Administering haloperidol without first attempting non-pharmacological interventions disregards the principle of using medications judiciously. While haloperidol may calm agitation, side effects such as sedation or movement disorders make it inappropriate as a first-line option. This choice should follow other measures.

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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?

Nursing Test Bank

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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?