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    Ati lpn med surg proctored exam (pain and shock)

    A nurse enters a client's room to answer the call light and sees the client is in the bathroom on the floor. Which of the following actions should the nurse take first?

    Explanation & Rationale

    Choice A rationale Notifying the client's provider is a necessary step after the immediate needs and physical assessment of the client are addressed and completed. The immediate priority following a fall is to ensure the client is safe, prevent further injury, and determine the extent of harm before reporting the incident to the healthcare provider for further medical orders. Choice B rationale Obtaining the client's vital signs is part of the assessment phase following a fall to establish a baseline and detect signs of injury (e.g., hypotension, shock). However, the initial priority is to safely return the client to the bed, which addresses the immediate risk of the client remaining on the cold, hard floor and attempting to move unsafely. Choice C rationale Assisting the client back into bed is the most immediate priority following a fall to ensure client safety and prevent complications such as hypothermia, pressure injury, or further injury from movement. This action addresses the immediate physical need before assessment, notification, or family communication can be effectively and safely performed. Choice D rationale Informing the client's family member is an important step in client and family communication regarding an adverse event. However, this is a subsequent step that must occur after the client's physical safety is secured, immediate care needs are met, and a thorough assessment of the fall and any resultant injuries has been performed.

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