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 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.
Correct Answer is C
Explanation
Choice A Reason:
Avoid entering the client's room unless requested during the night is inappropriate. While minimizing entries can reduce disruptions, it's important for the nurse to perform necessary checks and care interventions. Avoiding the room completely might compromise the client's safety or care.
Choice B Reason:
Turn off alarms on bedside monitoring equipment is inappropriate. Disabling alarms can jeopardize patient safety as these alarms often indicate critical changes in the client's condition. Adjusting alarm settings or investigating if noise levels can be reduced without compromising safety would be more appropriate.
Choice C Reason:
Conduct staff communications away from the client's room is appropriate. This intervention helps minimize noise levels near the client's room, creating a quieter environment conducive to sleep. Staff conducting communications away from the room reduces unnecessary disturbances that might affect the client's rest.
Choice D Reason:
Turn on the client's TV to distract from hallway noise is inappropriate. Introducing more noise, such as from a TV, might not effectively address the issue of sleep disturbance due to external noise. Additionally, it's essential to respect the client's preferences, and some may prefer a quiet environment for sleep rather than additional noise from a TV.
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