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 D

Explanation

Choice A rationale

A weight gain of 1 kg (2.2 lb) in 48 hours can be an early indicator of fluid retention in clients with heart failure. However, this change is not immediately life-threatening and can be addressed by monitoring or adjusting medications, making it lower priority compared to acute allergic reactions.

Choice B rationale

Paranoia in dementia clients reflects cognitive decline or psychological distress, which requires management but does not pose an immediate threat to physical health. It is important but not the highest priority for immediate reporting.

Choice C rationale

Progression of a pressure ulcer to stage III indicates worsening tissue damage, requiring evaluation of wound care strategies. However, this concern does not constitute an urgent situation compared to an acute allergic reaction that can compromise airway and systemic stability.

Choice D rationale

Itching after receiving cefaclor PO is a possible sign of an allergic reaction. Allergic reactions can escalate to anaphylaxis, posing immediate life-threatening risks. Recognizing and reporting this symptom promptly is critical for client safety.

A. Removing gloves before leaving an isolation room. B. Instructing a client to look down at their feet when being assisted to ambulate. C. Filling a basin with water at 40° C (104° F) when providing foot care. D. Applying water-soluble lubricant to the nares of a client who is receiving oxygen. E. None F. None

Correct Answer is B

Explanation

A. Removing gloves before leaving an isolation room: ✅ Appropriate. Gloves should be removed before exiting to prevent contamination.
B. Instructing a client to look down at their feet when ambulating: ❌ Unsafe. This increases the risk of falls. Clients should be encouraged to look straight ahead to maintain balance and awareness of their surroundings.
C. Filling a basin with water at 40°C (104°F): ✅ Safe and appropriate temperature for foot care.
D. Applying water-soluble lubricant to the nares of a client receiving oxygen: ✅ Acceptable. Water-soluble lubricants help prevent dryness and are safe to use with oxygen therapy.

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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?