A practical nurse enters a client's room and finds the client lying on the floor beside the bed. Arrange the following actions in the priority order the nurse should perform them, from first to last.
- 1Assess the client for changes in level of consciousness and any obvious injuries.
- 2Call for assistance from other nursing staff.
- 3Obtain the client's current vital signs.
- 4Assist the client safely back into bed.
- 5Notify the primary health care provider.
- 6Complete a facility incident report.
Answer
The correct sequence is: Assess the client, call for assistance, obtain vital signs, assist the client to bed, notify the provider, and finally complete the incident report.
When a client falls, the nurse must prioritize actions based on the nursing process (assessment first) and Maslow's hierarchy of needs. The absolute first step is to assess the client for any immediate life-threatening injuries or changes in consciousness. Second, the nurse calls for help because moving the client or conducting further assessment requires additional personnel. Third, the nurse obtains vital signs to ensure hemodynamic stability. Fourth, once cleared of contraindicating injuries, the client is safely returned to bed. Fifth, the primary health care provider is notified of the incident and assessment findings to obtain further orders. Finally, the nurse completes the facility's incident report, as administrative tasks are always the lowest priority in an emergency or acute event.
Step-by-Step Solution
Key Concept
The nursing process and prioritization guide post-fall management, emphasizing immediate assessment and client safety over administrative tasks.