A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take?

Document the completion of an occurrence report in the client's medical record.

Notify the client's provider about the occurrence.

Request another nurse to complete the occurrence report.

Contact risk management about the occurrence.

Answer and Explanation

The Correct Answer is B

A.   An occurrence report, also known as an incident report, documents the details of any unexpected event that occurs during the client's care. This includes falls. It is important to document the incident accurately and promptly in the client's medical record to ensure that all relevant information is recorded. However, this should not take priority over timely escalation of the issue.
B.   It is essential to notify the client's healthcare provider (such as the physician or nurse practitioner) about the fall incident. The provider needs to be informed about the client's condition after the fall, any injuries sustained, and any immediate actions taken.
C.   The nurse who witnessed or discovered the fall incident is responsible for completing the occurrence report. It should be filled out by the nurse who directly assessed the client's condition after the fall, documented any injuries, and initiated appropriate interventions. Asking another nurse to complete the report may not accurately reflect the details and actions taken by the nurse who was directly involved.
D.   Risk management may need to be informed about the fall incident, especially if it resulted in injury to the client. Risk management is responsible for assessing the circumstances surrounding the fall, identifying potential risks or contributing factors, and implementing strategies to prevent future incidents. However, contacting risk management is typically done after initial actions such as ensuring client safety, notifying the provider, and documenting the incident.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. This information highlights the importance of improving hand hygiene practices among healthcare workers. Low compliance rates indicate a need for education, reminders, and possibly changes in the healthcare facility's policies and procedures to encourage better adherence to hand hygiene protocols.
B. Hand hygiene is indeed one of the most critical measures to prevent the transmission of infections in healthcare settings. Proper hand hygiene (either washing with soap and water or using alcohol-based hand rubs) helps reduce the spread of pathogens from person to person, from surfaces to patients, and vice versa.
C. Alcohol-based hand sanitizers (gels, foams, or rubs) are effective and convenient for hand hygiene in healthcare settings. They are recommended by healthcare authorities like the CDC (Centers for Disease Control and Prevention) and WHO (World Health Organization) as they quickly reduce the number of microbes on hands when soap and water are not readily available or practical.
D. This statistic underscores the risk of healthcare-associated infections (HAIs) and the importance of preventive measures such as hand hygiene. Healthcare workers play a crucial role in reducing HAIs through proper hand hygiene practices.
E. Educating clients about hand hygiene is essential for infection prevention, especially in settings where clients can actively participate in their own care (e.g., hospitals, outpatient clinics, long-term care facilities). Clients should be encouraged to practice hand hygiene, particularly after using the restroom, before eating, and after touching surfaces that may harbor pathogens.

A. Instructions on mouth care B. Instructions to suction the client's tracheostomy every 2 hr C. Instructions on how to change ventilator settings D. Instructions to place the client in a supine position

Correct Answer is A

Explanation

A. Proper oral hygiene is crucial for preventing ventilator-associated pneumonia (VAP), which is a common complication in ventilated patients. The bundle often includes instructions on how to perform mouth care to reduce the risk of bacterial colonization in the oral cavity and subsequent aspiration into the lungs.
B. Tracheostomy care, including suctioning as needed, is important to maintain airway patency and prevent complications like mucus plugging. However, specific instructions for suctioning frequency (e.g., every 2 hours) may vary based on the patient's clinical condition and the presence of secretions. It is not universally part of the ventilator care bundle but is an essential component of managing patients with tracheostomies.
C. Correct ventilator settings are critical to support adequate oxygenation and ventilation while minimizing lung injury. Nurses should be knowledgeable about how to monitor and adjust ventilator settings based on the patient's respiratory status. Education on ventilator settings may be included in

training related to mechanical ventilation management, but it is not typically part of a standardized ventilator care bundle.
D. The position of the patient can affect ventilation and respiratory mechanics. In the context of ventilator care, positioning recommendations may include elevating the head of the bed (semi-Fowler's position) to reduce the risk of aspiration and improve lung expansion. Placing the client in a supine position alone is not specific to the ventilator care bundle but may be considered based on the patient's clinical condition.

View Question and Answer

A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Exhibits

A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching?

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Correct Answer is A

Explanation

A nurse is organizing interprofessional team members to meet the needs of a client. Which of the following roles is the nurse taking?

A school nurse receives a telephone call from a parent who suspects their school-age child may have coronavirus-2 (SARS-COV-2). Which of the following instructions should the nurse give as secondary prevention?

A nurse is providing discharge instructions to a client who has asthma and is about to start taking theophylline (Theo-24). The nurse should tell the client that this medication might cause which of the following adverse effects?

A nurse is caring for a 20-year-old client who has a fever and reports severe headache. Exhibits A nurse is preparing the client for a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take?

A nurse is discussing individual client factors that influence developing a communicable or infectious disease with a peer. Which of the following factors could increase a client's risk for contracting a communicable or infectious disease?

A charge nurse is teaching a newly licensed nurse about health care-associated infections (HAIs). Which of the following should the nurse include in the teaching as examples of HAIS?