A registered nurse enters a client's room and discovers the client lying supine on the floor next to the bed. Arrange the following nursing actions in the correct priority sequence from first to last.
- 1Determine the client's level of consciousness and assess airway, breathing, and circulation.
- 2Examine the client for any obvious physical injuries, active bleeding, or musculoskeletal deformities.
- 3Measure the client's vital signs and conduct a baseline neurological assessment.
- 4Safely assist the client back into the bed using a mechanical lift or additional staff members.
- 5Notify the primary healthcare provider and complete a facility occurrence report.
Answer
The correct sequence is to first assess the client's ABCs, then examine for physical injuries, obtain vital signs, safely return the client to bed, and finally notify the provider and complete an occurrence report.
The nursing process and prioritization frameworks (such as ABCs and 'assess before implementing') guide post-fall management. The nurse must first ensure immediate survival (ABCs), then evaluate for specific injuries caused by the fall. Vital signs provide hemodynamic context. Only when the client is deemed safe to move should they be returned to bed to prevent exacerbating any unidentified injuries. Finally, administrative and medical reporting is completed once the client is safe.
Step-by-Step Solution
Key Concept
Post-fall nursing management and injury prevention requires a systematic assessment to stabilize the client before moving them, followed by appropriate reporting.