The nurse is assigned to accept a new admission expected from the emergency department. As the client is wheeled off the elevator, which action by the nurse is the most appropriate?

Question

1. Waiting for the client to be placed in bed, then orienting the client to the unit
2. Accompanying the client and making introductions while assessing the client's mental status and appearance
3. Entering the client's room as soon as possible to obtain data for admission history
4. Asking the unlicensed assistive personnel to assist the client into bed

Answer 1

2
Rationale 1: Waiting for the client to be assisted into bed delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed.
Rationale 2: The initial assessment can begin as the nurse accompanies and assists the client to his room.
Rationale 3: After the client is placed in bed, the nurse would begin by assessing the client, obtaining data for the admission history during the examination.
Rationale 4: Asking the unlicensed assistive personnel to help the client delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed.
Global Rationale: The initial assessment can begin as the nurse accompanies and assists the client to his room. Waiting for the client to be assisted into bed or asking the unlicensed assistive personnel to help the client delays the initial assessment required to determine the client's acuity and orientation, which could impact room placement, equipment needed, and the client's overall outcome if needed care is delayed. After the client is placed in bed, the nurse would begin by assessing the client, obtaining data for the admission history during the examination.