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 C
Explanation
A. Delayed gastric emptying (gastroparesis) typically manifests with symptoms related to the gastrointestinal system, such as nausea, vomiting, bloating, and early satiety. It does not cause changes in lung auscultation findings.
B. Pulmonary edema is characterized by the accumulation of fluid in the lungs, leading to symptoms such as shortness of breath, crackles (rales) on lung auscultation, and possibly decreased oxygen saturation. While pulmonary edema can cause abnormal lung sounds, it is less likely in a client recovering from a lacerated spleen unless there are additional complications or comorbidities.
C. Atelectasis refers to the collapse or closure of a part of the lung, resulting in reduced or absent air exchange. It can occur due to prolonged bedrest, shallow breathing, or conditions that restrict lung expansion. A client who has been on bedrest for several days is at increased risk for developing atelectasis, especially in the lower lobes where ventilation may be compromised. Decreased breath sounds in the lower lobes suggest atelectasis as a likely condition.
D. An upper respiratory infection typically affects the upper airways (nose, throat, sinuses), causing symptoms such as nasal congestion, sore throat, cough, and sometimes fever. Lung auscultation findings in an upper respiratory infection are more likely to include rhonchi or wheezes rather than decreased breath sounds in the lower lobes.
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.
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