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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Inflating the catheter's balloon is done after proper placement to secure the catheter in the bladder. It should not be done when there is resistance and no urine flow.
Choice B Reason:
Twisting the catheter gently is correct. Resistance during catheter insertion may indicate the catheter is encountering an obstruction or is misaligned. Gently twisting the catheter can help navigate around obstructions or correct misalignment without causing trauma to the urethra.
Choice C Reason:
Applying lidocaine gel to the urethra is typically used for lubrication and to numb the urethra during catheter insertion, but it may not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is not a standard action in response to resistance during catheter insertion. Twisting the catheter gently is a more appropriate initial step.
Correct Answer is C
Explanation
Choice A Reason:
Requesting a medication reconciliation form from the pharmacy is not the immediate step needed for a missed dose. Contacting the previous nurse provides more timely information.
Choice B Reason:
Asking the client if she received the 1700 medication is not the first action to take. The nurse should first investigate the missing documentation through collaboration with the healthcare team.
Choice C Reason:
Contacting the previous nurse to determine if the client received the medication is correct. Contacting the previous nurse is a reasonable and responsible step to gather information about the missed medication. The previous nurse may have insights into why the documentation is missing and whether the medication was administered.
It allows for collaboration and communication among healthcare providers, ensuring accurate and comprehensive information about the client's care. Administering the medication without clarification may lead to a potential double dose if the previous dose was indeed administered.
Choice D Reason:
Administering the medication and documenting the current time without confirming the missed dose could result in an inaccurate representation of the client's medication history and potential harm if the previous dose was already administered. It is crucial to gather information before taking further action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.