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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A decrease in systolic blood pressure from 140 mm Hg to 120 mm Hg could indicate hypotension. Postoperatively, especially after receiving a spinal anesthetic, hypotension can occur due to vasodilation or decreased sympathetic tone. This change in blood pressure warrants notification of the provider because significant hypotension can lead to inadequate perfusion to vital organs and tissues.
B. A slight increase in temperature from 37.2°C to 37.5°C (99.0°F to 99.5°F) is a mild elevation and may not necessarily require immediate notification unless accompanied by other signs of infection or instability. It could be related to the stress response post-surgery. However, if there are other concerning signs (e.g., increased heart rate, worsening pain), the nurse should reassess and consider further action.
C. A decrease in pulse oximetry from 98% to 96% indicates a mild decrease in oxygen saturation. While this change alone may not be alarming, the nurse should assess the client's respiratory status and potential causes (e.g., positioning, respiratory depression from anesthesia). Oxygen saturation levels below 95% generally require intervention, but 96% is still within a normal range for most clients.
D. An increase in pain from 4/10 to 6/10 indicates worsening pain. Postoperatively, increasing pain may indicate inadequate pain management, worsening condition at the surgical site, or other complications such as hematoma or infection.
Correct Answer is A
Explanation
A. Diazepam is a benzodiazepine commonly used in the management of alcohol withdrawal syndrome. Benzodiazepines are effective in reducing symptoms such as anxiety, tremors, agitation, and preventing seizures that can occur during alcohol withdrawal. Diazepam is preferred due to its rapid onset and long duration of action, which helps stabilize the client during withdrawal.
B. Buprenorphine is a partial opioid agonist typically used in the treatment of opioid dependence, not alcohol withdrawal. It is not recommended as a first-line medication for alcohol withdrawal management.
C. Disulfiram is used as an aversive therapy in the treatment of alcohol use disorder. It works by causing unpleasant symptoms (such as nausea, vomiting, palpitations) if the client consumes alcohol. It is not indicated for the treatment of alcohol withdrawal symptoms.
D. Methadone is a synthetic opioid agonist primarily used for the treatment of opioid dependence and chronic pain management. It has no role in the treatment of alcohol withdrawal and is not appropriate for managing symptoms associated with alcohol withdrawal.
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