Editing Infection Control and Safety – RN Practice Questions (section)

==Question 12==
Following an unwitnessed fall, a client is found on the floor next to the bed. The client takes apixaban. Which action should the nurse take '''first'''?
# Assist the client back to bed with help from another staff member.
# Complete an incident report and document that it was filed in the medical record.
# Assess the client's level of consciousness, vital signs, and for injury before moving them.
# Notify the provider and request a head computed tomography scan.

'''Answer:''' 3. Assess the client's level of consciousness, vital signs, and for injury before moving them.

''Rationale:'' Moving a client before assessment can convert an occult fracture or spinal injury into a worse injury. Assessment comes first. Provider notification and imaging follow, and are especially important with an anticoagulant and an unwitnessed fall, since intracranial hemorrhage may be delayed and neurologic checks are indicated. An incident report is an internal quality document; it is completed, but the medical record should not state that one was filed.