A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?
Notify the nurse manager.
Complete an incident report.
Obtain the family member's health history.
Check the family member's vital signs.
The Correct Answer is D
A. Notifying the nurse manager is important, but it is not the immediate priority when a family member has fainted.
B. Completing an incident report is necessary for documentation but should occur after addressing the immediate medical concern.
C. Obtaining the family member's health history is not pertinent at this moment as the priority is to assess their current condition.
D. Checking the family member's vital signs is the first action to determine their immediate health status and any necessary interventions to provide appropriate care.
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Correct Answer is D
Explanation
A. Consulting the ethics committee is unnecessary at this stage, as there is no ethical dilemma in arranging social support services.
B. Suggesting a discharge delay is premature and may not be feasible; alternative support should be considered first.
C. Long-term care facility placement is a more permanent solution and may not align with the client’s needs or preferences.
D. Recommending a referral to social services is appropriate as social services can help arrange post-discharge support, including home health services or community resources, ensuring a safe transition home.
Correct Answer is D
Explanation
A. Using only room numbers for client identification does not guarantee confidentiality, as room numbers can still be linked to specific individuals.
B. Logging assistive personnel into unit computers compromises security and violates confidentiality protocols. Each user should have a unique login.
C. Including a client’s name on a fax cover sheet is not recommended, as it exposes protected health information and can breach confidentiality.
D. Conducting change-of-shift report in a staff-only area protects client information from being overheard by unauthorized individuals, ensuring confidentiality.