A practical nurse (PN) enters a client's room and finds the client lying on the floor. The client is awake, responsive, and states, 'I tried to walk to the bathroom, but my legs gave out.' In which order should the PN perform the following actions? Arrange the actions from first priority to last.
- 1Assess the client for physical injuries, vital signs, and level of consciousness.
- 2Call for additional staff assistance to help with the client.
- 3Assist the client safely back into bed using appropriate transfer techniques.
- 4Notify the healthcare provider and complete a facility incident report.
Answer
The correct priority sequence is to first assess the client for injuries, then call for staff assistance, safely assist the client back to bed, and finally notify the provider and complete an incident report.
Following a client fall, the nursing process dictates that assessment is the absolute first priority. The PN must immediately determine if the client sustained a head injury, fracture, or change in consciousness before taking any other action. After confirming the client's status and ensuring it is safe to move them, the PN calls for help to facilitate a safe transfer. Once sufficient staff is present, the client is moved back to bed using proper ergonomics. Finally, administrative and collaborative duties, such as notifying the primary healthcare provider for follow-up orders and filing an incident report, are completed once the client is safe and stabilized.
Step-by-Step Solution
Key Concept
Post-Fall Assessment and Priority Management