A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

Use direct quotes made by the client to describe the incident.

Make a notation in the client's medical record that an incident report was completed.

Draw a conclusion regarding the cause of the incident.

Place a copy of the incident report in the client's medical record.

Answer and Explanation

The Correct Answer is A

Choice A Reason:Using direct quotes from the client in the incident report is appropriate because it provides an accurate and objective account of the client's perspective. This is an important part of documenting the incident.

Choice B Reason:Incident reports are meant to be internal documents used for quality improvement and risk management. Noting in the medical record that an incident report was completed is not appropriate, as it could imply liability or affect the legal status of the report.

Choice C Reason:The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.

Choice D Reason:
The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.

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Correct Answer is B

Explanation

Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.

Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.

Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.

Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.

A. "This type of device is useful for a client who cannot assist." B. "The lower end of the sling goes below the client's calves." C. "The sides of the sling are for the client to hold on to." D. "The device requires the client to use upper body strength."

Correct Answer is A

Explanation

Choice A Reason:

"This type of device is useful for a client who cannot assist." This statement accurately reflects the purpose of a mechanical lift. Mechanical lifts are designed to assist individuals who have limited or no weight-bearing capacity, making them suitable for clients who cannot actively participate in the transfer process. These devices provide support and aid in moving the client safely and comfortably.

Choice B Reason:

"The lower end of the sling goes below the client's calves. This statement is incorrect. The lower end of the sling typically goes under the client's thighs, not below the calves. Placing the sling under the thighs provides proper support and stability during lifts and transfers.

Choice C Reason:

"The sides of the sling are for the client to hold on to." This statement is incorrect. The sides of the sling are not meant for the client to hold on to. The sling is designed to cradle and support the client's body during transfers, ensuring a secure and comfortable lift without relying on the client's strength.

Choice D Reason:

"The device requires the client to use upper body strength." This statement is incorrect. The primary purpose of a mechanical lift is to minimize the physical effort required from the client. These devices are designed to lift and transfer clients with minimal assistance from the client, reducing the risk of injury and ensuring a safe transfer for both the client and the caregiver.

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A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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