As a patient is ambulating to the bathroom, they fall. Which initial action will the nurse take next to ensure the care plan is accurately revised?
Assess the client
Establish a new plan of care.
Consult physical therapy.
Set new priorities for the patient.
The Correct Answer is A
A. Assessment is the first and most critical step of the nursing process following any adverse event like a fall. The nurse must collect data on the patient's physical and neurological status to identify any immediate injuries or changes in condition. This objective and subjective information is the prerequisite for making any meaningful revisions to the patient's care plan.
B. Establishing a new plan of care cannot occur until a comprehensive assessment has been performed to determine why the fall occurred and what new needs exist. Jumping directly to planning without data collection leads to ineffective or inappropriate interventions. The assessment findings will dictate the specific modifications required to ensure the patient's future safety and recovery.
C. Consulting physical therapy may be a necessary later step to address gait or balance issues, but it is not the initial action for revising the nursing care plan. The nurse must first evaluate the patient's immediate safety and clinical status following the incident. Physical therapy serves as a collaborative intervention that is informed by the nurse's initial post-fall assessment.
D. While priorities will likely change after a fall, the nurse must first assess the patient to understand what those new priorities should be. For example, the priority might shift to pain management or neurological monitoring based on the assessment findings. Setting priorities is a component of the planning phase, which must always be preceded by the assessment phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Assessment of a postoperative client requires advanced clinical judgment to identify potential complications like hemorrhage or anesthesia reactions. This task is strictly within the scope of practice of the registered nurse and cannot be delegated to unlicensed personnel. The nurse must personally evaluate the patient's stability and physiological response following a major surgical procedure.
B.Obtaining vital signs, such as blood pressure, on a stable client is a routine task that falls within the job description of assistive personnel. Since the client is stable and preparing for discharge, this task does not require complex clinical interpretation by the nurse at the moment of collection. The nurse remains responsible for reviewing the results and ensuring they are within expected limits.
C.Tracheostomy care is an invasive procedure that involves the airway and requires specialized knowledge of sterile technique and respiratory assessment. Due to the high risk of complications such as airway obstruction or infection, this task must be performed by a licensed nurse. Assistive personnel are not trained to manage artificial airways or assess the integrity of the stoma.
D.Patient teaching is a core nursing responsibility that involves evaluating the patient's readiness to learn and their understanding of the material. While an AP can encourage a patient to use the device, the initial instruction and demonstration must be performed by the registered nurse. Effective teaching requires the clinical expertise to explain the rationale and correct the patient's technique.
Correct Answer is B
Explanation
A.While reviewing potassium levels is important for certain antihypertensive medications like diuretics or ACE inhibitors, it is not the priority when a patient presents with a hypertensive reading. The immediate concern is the patient's elevated blood pressure and the specific parameters set by the provider. Laboratory review should follow the immediate clinical assessment and notification required by the order.
B.Holding the medication is necessary because the patient's diastolic pressure (100) exceeds the provider's threshold (90). Assessing the patient for symptoms such as headache, blurred vision, or chest pain is the critical next step to determine the severity of the hypertensive state. Notifying the provider after the assessment allows the nurse to provide a complete clinical picture for further medical orders.
C.Administering the medication despite the diastolic pressure being 100 would be a direct violation of the provider's order to notify them first. This could potentially harm the patient if the medication is inappropriate for the current clinical state. Nurses must strictly adhere to provided parameters to ensure patient safety and maintain legal standards of care.
D.Holding the medication and calling the physician is an incomplete action because it skips the essential step of patient assessment. A nurse must never call a provider without first obtaining current assessment data, such as neurological or cardiovascular symptoms. The provider will require this information to make an informed decision regarding the patient's treatment and potential level of care.
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