A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?
Record in the nurse's notes that an incident report was filed.
Give the family a copy of the incident report.
Document the facts about the incident in the medical record.
Place a copy of the incident report in the medical record.
The Correct Answer is C
A. While the nurse's notes may include observations about the client's condition, recording that an incident report was filed does not provide pertinent details regarding the client's care and is not appropriate.
B. Incident reports are confidential documents and should not be shared with the client's family, so providing a copy of the report is inappropriate.
C. Documenting the facts about the incident in the medical record is essential to provide a complete account of the client's care and any resulting changes or observations. This documentation is important for continuity of care and legal purposes.
D. Incident reports should not be placed in the medical record, as they are separate documents intended for internal review and quality assurance purposes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Client 1: The client with Pertussis should have individuals wear surgical masks when within 3 feet of the client, not 1 foot. Pertussis is highly contagious, and proper precautions are necessary to prevent transmission
B. Client 2: The client with Clostridium difficile is placed in a private room, and nurses wear gowns and gloves during direct care. These are appropriate contact precautions for preventing the spread of C. difficile.
C. Client 3: The client with Herpes simplex is managed with nurses wearing gowns and gloves during direct care, which is appropriate for preventing the spread of the virus through direct contact.
D. Client 4: The client with Mycobacterium tuberculosis should be placed in a negative airflow room, not a positive airflow room. Negative airflow rooms help contain airborne pathogens and prevent them from spreading to other areas.
E. Client 5: The client with Streptococcal pharyngitis is placed in a private room, and the client wears a surgical mask when transported outside their room. These are appropriate droplet precautions to prevent the spread of infection.
Correct Answer is B
Explanation
A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.
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