A nurse has entered the room of a patient with cirrhosis and found the patient on the floor
The patient states that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action?
A) Remove the patient's commode and supply a bedpan.
B) Complete an incident report and submit it to the unit supervisor.
C) Have the patient assessed by the physician due to the risk of internal bleeding.
D) Perform a focused abdominal assessment in order to rule out injury.
Ans: C
Feedback:
A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.
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