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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. An advance directive is a legal document that outlines a person's preferences for medical treatment, including end-of-life care. Asking the client if they have a copy of their advance directive is appropriate because it can provide valuable information about their wishes regarding medical interventions. It allows the nurse to review the document to ensure that the client's current wishes align with what is documented in their advance directive.
B. In most cases, a competent adult's healthcare decisions, including decisions to refuse treatment, are legally binding and cannot be overridden by family members. It is important for the nurse to educate the client about their rights and ensure that their wishes are respected. Family members may be involved in discussions and support the client's decisions, but they cannot override a competent adult's wishes regarding their medical care.
C. While it's important to involve family members in discussions about the client's wishes, especially if they are the client's designated healthcare proxy or legally authorized decision-maker, family agreement is not required for the client's decision to refuse life-saving measures. The nurse should primarily focus on the client's expressed wishes and ensure that these wishes are understood and respected.
D. The provider's agreement with the client's decision may be necessary to document and implement the plan of care accordingly, but ultimately, the decision to refuse treatment rests with the competent client. The nurse should facilitate communication between the client and the provider to ensure that the client's wishes are understood and documented appropriately.

A. "I am unable to discuss this, but I can contact my supervisor to speak with you." B. "As a nurse, I am required by law to report suspected child abuse." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

Correct Answer is B

Explanation

A. This response acknowledges the parent's concern but maintains confidentiality regarding the report. It offers to involve the supervisor, which is a reasonable step. However, it may leave the parent feeling uneasy or uncertain.
B. This response directly informs the parent about the legal obligation of the nurse to report suspected child abuse. It provides clarity on why the nurse took action. However, it might be perceived as abrupt or lacking empathy.
C. This response suggests that someone else (possibly a healthcare provider or another authority figure) will explain the situation later. It doesn't directly address the reason for the nurse's action or the legal requirement to report.
D. This response explains the chain of events, from reporting to the supervisor's decision to contact authorities. It provides information but might not directly address the parent's emotional concern or the legal obligation of the nurse.

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 nurse is admitting a client who requests not to be intubated or have any other life saving measures initiated. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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 is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include?

A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

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

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

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?