A nurse is assisting with a quality improvement project to decrease client falls. Which of the following activities should the nurse perform?
Document an incident report in a client's medical record.
Notify the provider if a client fails
Assist with the care of a client who has fallen.
Collect data about each fall
The Correct Answer is D
A. Document an incident report in a client's medical record: Incident reports are essential for internal documentation but should not be placed in the client’s medical record. Including them in the medical record can lead to legal complications. This action addresses individual events rather than contributing to systematic quality improvement efforts.
B. Notify the provider if a client falls: Notifying the provider about a fall is a necessary clinical step to ensure immediate evaluation and care for the client. However, simply informing the provider does not contribute directly to a quality improvement initiative aimed at analyzing and reducing overall fall rates.
C. Assist with the care of a client who has fallen: Providing immediate care after a fall is crucial to ensure client safety and manage injuries. However, assisting after the fall focuses on acute clinical response rather than on proactive measures to identify trends and reduce the incidence of future falls.
D. Collect data about each fall: Collecting data is a fundamental part of quality improvement projects. By systematically gathering information on when, where, and how falls occur, patterns can be identified, leading to the development of targeted interventions aimed at preventing future incidents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.
B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.
C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.
D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.
Correct Answer is D
Explanation
A. Apply a 9 kg (20 lb) weight to the traction: Buck’s traction is designed for short-term immobilization and uses lighter weights, typically between 2 to 5 kg (4.5 to 10 lb). Applying 9 kg (20 lb) would be excessive and could lead to nerve damage, impaired circulation, or additional injury.
B. Clean the pin insertion sites on a daily basis: Buck’s traction is a type of skin traction, not skeletal traction, and does not involve pins inserted into the bone. Therefore, there are no pin sites to clean in Buck’s traction, making this action irrelevant for the client’s care.
C. Remove the weights while the client is eating: Weights should never be removed or lifted unless there is a provider’s specific order to do so. Interrupting the continuous pull of the traction can cause misalignment of the fracture and delay healing.
D. Ensure that the weights are hanging freely: It is essential that the weights in Buck’s traction hang freely without resting on the floor or bed. This ensures a constant, steady pull on the extremity, which helps maintain proper alignment and promotes effective immobilization.
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