A nurse is caring for a client who has fallen while getting out of bed and states, “I’m okay! I guess I should have called for help to the bathroom.” After assessing the client, the nurse notifies the provider.
Which of the following documentation should the nurse include in the client’s medical record?
An incident report was completed
There were no injuries sustained
The provider was notified
An incident report was forwarded to risk management
The Correct Answer is C
Correct Answer: C
C. The provider was notified. The nurse should document objective facts, such as notifying the provider, in the client’s medical record. This ensures accurate communication about the client's condition and the steps taken after the fall.
Incorrect answers:
A. "An incident report was completed." The completion of an incident report should not be documented in the medical record. Incident reports are internal documents used for quality improvement and risk management, and mentioning them in the medical record could make them discoverable in legal proceedings.
B. "There were no injuries sustained." While documenting the client’s physical condition is appropriate, stating "no injuries sustained" might be premature or subjective. Instead, the nurse should record specific observations, such as "client denies pain" or "no visible signs of injury noted."
D. "An incident report was forwarded to risk management. Referencing the incident report in the medical record is inappropriate. Incident reports are separate from the client’s medical record and should not be mentioned in the documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Performs auscultation between meals:
Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.
B. Clamps the Naso Gastric tube during auscultation
Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.
C. Palpates the abdomen prior to performing auscultation:
Palpating the abdomen before auscultation may interfere with normal bowel sounds
D. Auscultates bowel sounds for 3 to 5 min:
Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.
Correct Answer is ["20"]
Explanation
To administer the ordered dose of furosemide (Lasix) 20mg, you need to calculate the amount of mL required from the available solution. The available solution has a concentration of 2 mg/2 mL, which means that for every 2 mL of solution, there are 2 mg of furosemide. To find the amount of mL needed to deliver 20 mg of furosemide, you can use the following formula:
mL = (ordered dose / available dose) x available volume
Plugging in the values, we get:
mL = (20 mg / 2 mg) x 2 mL
mL = 10 x 2 mL
mL = 20 mL
Therefore, you need to administer 20 mL of the available solution to give the patient 20 mg of furosemide.
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