A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used. A)Assess for presence of adequate pulse B)Complete an incident report C)Get help and move the client to the bed D)Inspect the client for injuries E)Notify the client's health care provider (HCP)

Question

Quizplus · Accepted Answer

Establishing the presence of the client's ABCs/physiological stability is first step as the client could have lost consciousness or had a cardiovascular event that caused the fall. The need for immediate resuscitation should be assessed first (Option A). The presence of gross injuries should be established prior to moving the client so that appropriate immobilization can be taken. If awake, clients should be asked what body parts were struck, how they fell, if they hit their head, and what currently hurts. The spine should be immobilized and a cervical collar used for any neck pain (Option D). Additional help should be obtained to move the client to proper position at the site and avoid injury to the staff. After emergent stabilization, the client should be returned to bed for vital signs and further assessment (Option C). The HCP should be notified of the incident and assessment findings (Option E). Documentation should be made in the client's chart and an incident report filed for risk management (Option B). Educational objective: The appropriate order of actions when a client is found on the floor is assessment of stability, assessment of injuries, moving the client, notifications, and documentation.

A Client on Fall Precautions Is Found on the Floor