Question

The nurse is planning care for a client in the emergency department (ED). Select the 5 actions the nurse should plan to take.

A) Initiate a comprehensive physical assessment
B) Administer prescribed pain medication
C) Obtain a detailed medical history
D) Monitor vital signs regularly
E) Establish intravenous (IV) access
F) Implement fall precautions
G) Document the client's chief complaint
H) Request laboratory tests as needed
I) Provide emotional support to the client and family
J) Collaborate with other healthcare providers for further evaluation
K) Prepare the client for immediate surgery if required
L) Educate the client on self-care measures post-discharge

Answer 1

The nurse should plan to initiate a physical assessment, establish IV access, monitor vital signs regularly, implement fall precautions, and document the client's chief complaint.

Step-by-step explanation:

The nurse should plan to take the following 5 actions:

1. Initiate a comprehensive physical assessment: This involves conducting a thorough assessment of the client's physical health, including examining vital signs, performing a head-to-toe assessment, and assessing any potential injuries or illnesses.
2. Establish intravenous (IV) access: This involves inserting an IV line to administer fluids, medications, or blood products if necessary.
3. Monitor vital signs regularly: This involves regularly checking and recording the client's vital signs, such as blood pressure, heart rate, respiratory rate, and temperature, to ensure their stability and identify any changes or abnormalities.
4. Implement fall precautions: This involves taking appropriate measures to prevent falls, such as providing a safe environment, assisting the client with mobility, and using devices like bed alarms or bedrails.
5. Document the client's chief complaint: This involves recording the client's main reason for seeking care in the emergency department, which helps guide the nursing and medical interventions.