A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Notify the client's provider: Notifying the provider is important if there is concern for injury, but this should follow the initial assessment to determine the client’s condition. Immediate evaluation takes priority to identify any life-threatening or urgent issues. B. Measure the client's vital signs: Assessing vital signs is the first action because it provides critical information about the client’s hemodynamic status and identifies potential injuries or complications, such as internal bleeding or shock, following the fall. This guides subsequent interventions and provider notification. C. Complete an incident report: Completing an incident report is necessary for legal and quality improvement purposes, but it is not the first priority. The client’s safety and clinical assessment take precedence over documentation. D. Document the fall in the client's medical record: Accurate documentation is essential for continuity of care and legal reasons, but it should occur after assessing the client’s condition and initiating any necessary interventions.