A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?

Make a copy of the incident report for the provider.

Submit the incident report to the risk manager.

Place the incident report in the client's chart.

Document in the chart that an incidence report has been filed.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Making a copy of the incident report for the provider is not necessary; the report should be handled according to the facility’s protocol.

B. Submitting the incident report to the risk manager ensures it is reviewed and addressed appropriately, which is crucial for risk management and quality improvement.

C. Placing the incident report in the client’s chart is not appropriate as it is considered a confidential document related to quality and safety, not part of the client’s medical record.

D. Documenting in the chart that an incident report has been filed is not sufficient; the report should be submitted to the risk management team for review.

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Correct Answer is A

Explanation

Rationale:

A. Assessment includes the current status and vital signs of the client, which are part of the information the nurse provides to assess the client’s condition.

B. Situation describes the problem or concern that prompted the communication, not detailed vital signs.

C. Background provides context or history relevant to the situation but does not include current vital signs.

D. Recommendation involves suggesting actions or solutions but does not include the current condition details.

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) B. A client who has diarrhea and requests clear liquids for breakfast C. A client who has a cast on the left leg and reports numbness and paresthesia D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150

Correct Answer is C

Explanation

Rationale:

A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.

B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.

C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.

D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.

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A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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