Nokea
A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient?
Correct Answer: A
Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls.
Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall.
Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall.
Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.