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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Take the blood pressure:

Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.

B. Remove the pillow from under the patient’s head:

Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.

C. Elevate the foot of the bed:

Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.

D. Elevate the head of the bed:

Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.

A. Change the plan of care to provide different pain relief interventions B. Reassess the client to determine the reasons for inadequate pain relief C. Teach the client about the plan of care for managing his pain D. Wait to see whether the pain lessens during the next 24hours

Correct Answer is B

Explanation

A. Change the plan of care to provide different pain relief interventions:

While changing the plan of care may be necessary, it should be based on a thorough reassessment. Simply changing the plan without understanding the reasons for inadequate pain relief may not lead to effective outcomes.

B. Reassess the client to determine the reasons for inadequate pain relief.

Reassessment is a crucial step in the nursing process, especially when the desired outcomes are not achieved. By reassessing the client, the nurse can identify any factors contributing to the inadequate pain relief. This might include reevaluating the effectiveness of the current pain relief interventions, ensuring proper administration of medications, considering changes in the client's condition, or exploring any new factors affecting pain.

C. Teach the client about the plan of care for managing his pain:

Teaching is an important aspect, but in this case, reassessment takes precedence. Once the reasons for inadequate pain relief are determined, teaching can be tailored to address specific needs.

D. Wait to see whether the pain lessens during the next 24 hours:

If the pain is not adequately controlled, waiting for another 24 hours without action may prolong the client's discomfort and delay appropriate interventions. Reassessment and prompt adjustments to the plan of care are crucial for effective pain management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is having dyspnea. What would the nurse do first?

Correct Answer is A

Explanation

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Correct Answer is B

Explanation

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