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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Discarding the vial with the remaining medication in the sharp container is inappropriate. This would result in unnecessary waste of the medication and could lead to increased healthcare costs.
Choice B Reason:
Having another nurse witness the disposal of the remaining medication is inappropriate. Witnessing the disposal is typically required for controlled substances, but in this situation, it's more appropriate to use the remaining medication with appropriate documentation.
Choice C Reason:
Drawing up the remaining 1 mg in a syringe and label it with the contents, date, and time is appropriate. This approach minimizes medication wastage and allows for appropriate documentation of the extra dose drawn up. However, it is crucial to label the syringe clearly with the contents, date, and time to avoid any potential errors or confusion. This labeled syringe can then be used for subsequent doses, as long as it remains within the medication's expiration period and adheres to institutional policies.
Choice D Reason:
Storing the vial in the client's medication drawer for future use is inappropriate. Keeping the vial for future use without appropriate documentation is not recommended, as it may lead to medication errors or confusion.
Correct Answer is D
Explanation
Choice A Reason:
Muscle weakness is incorrect. Muscle weakness can be a symptom of hyperkalemia (elevated potassium levels). However, it is not the most urgent symptom, and the provider should be informed to address the underlying cause.
Choice B Reason:
Paresthesias is incorrect. Paresthesias (tingling or numbness) can also occur with hyperkalemia. While important to assess, it may not be the most urgent symptom requiring immediate attention.
Choice C Reason:
Abdominal cramps is incorrect. Abdominal cramps can be associated with hyperkalemia, but they are not the most critical symptom. It's essential to address the underlying cause, but it may not require immediate intervention compared to other symptoms.
Choice D Reason:
Palpitations is correct. Palpitations are a concerning symptom, especially in the context of hyperkalemia. Elevated potassium levels can lead to cardiac arrhythmias, and palpitations may be indicative of serious cardiac complications. This is a critical finding that requires immediate attention from the healthcare provider.
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