A nurse hears a loud noise from a client's room and enters to find the client lying on the floor. Arrange the following nursing actions in the correct chronological order from first to last.
- 1Assess the client's responsiveness, airway, and breathing.
- 2Inspect the client for visible injuries, bleeding, or suspected fractures.
- 3Obtain a baseline set of vital signs while the client is still on the floor.
- 4Utilize a mechanical lift and additional staff to safely return the client to bed.
- 5Notify the primary healthcare provider and complete a facility incident report.
Answer
The correct sequence is to first assess responsiveness and ABCs, then inspect for physical injuries, followed by obtaining vital signs, returning the client to bed, and finally notifying the provider and completing an incident report.
This sequence follows the nursing process and the ABCs prioritization framework. When a client falls, the immediate priority is to assess for life-threatening conditions (responsiveness and airway). Next, the nurse must rule out physical injuries (like a hip fracture or head trauma) before moving the client, as premature movement can exacerbate injuries. Vital signs provide further assessment data regarding the client's stability. Only after confirming the client is stable and uninjured should they be moved. Finally, reporting and documentation are completed once the client is safe.
Step-by-Step Solution
Key Concept
Post-Fall Nursing Assessment and Prioritization