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.
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Related Questions
Correct Answer is D
Explanation
A. QD (every day) is not an approved abbreviation due to the potential for misinterpretation, so it should not be used.
B. HS (at bedtime) is also not recommended as it can be confused with "half-strength," so it is not an approved abbreviation.
C. SQ (subcutaneous) is not commonly used in current practice as abbreviations may lead to errors; the term should be written out as "subcut" or "subcutaneously."
D. PO (by mouth) is an accepted and approved abbreviation used to indicate that a medication is to be taken orally, making it the correct choice for inclusion in the in-service.
Correct Answer is D
Explanation
A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.
B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.
C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.
D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.
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