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.

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Correct Answer is D

Explanation

A. This scenario describes a near-miss or a close call, where an error occurred but was intercepted before reaching the patient. While it is a significant incident that requires investigation and corrective action, it does not meet the criteria for a sentinel event because there was no actual harm to the patient.
B. This option could be related to the natural course of the patient's illness or underlying condition.
C. This incident involves a medication error where a potentially harmful medication was prescribed but not administered due to cancellation. Since the medication was not administered and no harm occurred to the patient, this does not meet the criteria for a sentinel event. It is a medication error that warrants investigation and review to prevent future occurrences.
D. This is because patient falls are specifically mentioned as one of the most commonly reported sentinel events, which can result in serious injury or death.

A. Call the health care provider for further instructions. B. Ensure the client has been taking their prescribed diuretic. C. Reinforce the importance of daily weights. D. Document the findings and continue with the visit.

Correct Answer is A

Explanation

A. Calling the healthcare provider is a reasonable action, especially when there is a significant change in the patient's condition, such as weight gain and generalized edema. The nurse may need further guidance on adjusting medications or additional interventions.

B. Diuretics are commonly prescribed for patients with heart failure to manage fluid overload. If the patient has not been compliant with taking their diuretic as prescribed, it could contribute to fluid retention and exacerbation of symptoms. Therefore, ensuring medication adherence is important. However, this alone may not address the acute issue of current weight gain and edema.
C. Daily weight monitoring is crucial for patients with heart failure as it can indicate fluid retention early on. Reinforcing the importance of daily weights helps in early detection of changes and facilitates timely intervention. However, in this scenario, the nurse has already noted a significant weight gain and edema since the last visit, so immediate action beyond education is needed.
D. Documenting the findings is essential for maintaining accurate patient records. However, in the context of a patient with heart failure who has shown signs of worsening (weight gain and edema), immediate action to address the worsening condition is necessary.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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