A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?
Contact the nurse manager.
Call risk management to interview the client.
Reassure the client that the staff is well trained.
Document in the client's chart that an incident report has been filed.
The Correct Answer is A
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B. Yellow tags are used for those who require observation but are not in immediate danger.
C. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D. Green tags are used for individuals with minor injuries or those who require minimal medical assistance.
Correct Answer is D
Explanation
A. Mentioning that the client is the president of a local bank might not be pertinent to the client's current health status or care needs and is not typically included in a change-of- shift report unless relevant to the care plan.
B. The fact that the client's partner came to visit two hours ago might be important for emotional support or social interaction but might not be crucial information for the oncoming nurse unless relevant to the client's condition.
C. The client has routine vital signs prescribed”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
D. This is critical information for the incoming nurse. It informs them that the client is currently away from the unit, which may affect the plan of care, including monitoring, medication administration, or any interventions needed during the client’s absence. It is important for the incoming nurse to be aware of the client's current status and whereabouts.
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