A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
The client fell because the assistive personnel did not place nonskid slippers on the client."
The client does not appear to have any injuries resulting from the fall."
"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
"An incident report has been completed and sent to risk management."
The Correct Answer is C
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
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Naxlex Comprehensive Predictor Exams
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Explanation
The correct answer is C. Putting soiled dressings in a tied plastic bag before placing them in the trash reduces the risk of exposure to blood-borne pathogens for anyone who handles the trash.
Correct Answer is C
Explanation
The correct answer is C. "Close your mouth around the mouthpiece." The rationale for this instruction is that it ensures that the medication reaches the lungs and does not escape through the mouth or nose. Albuterol is a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs. It is used to treat or prevent bronchospasm, or narrowing of the airways, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm. Albuterol is delivered through a metered dose inhaler (MDI), which is a device that releases a measured amount of medication with each puff. To use an albuterol MDI correctly, the client should follow these steps :
- Shake the inhaler well before each spray.
- Remove the cap and look at the mouthpiece to make sure it is clean.
- Breathe out fully.
- Put the mouthpiece between your lips and close your mouth around it.
- Press down on the inhaler to release the medication as you start to breathe in slowly.
- Breathe in slowly and deeply over 3 to 5 seconds.
- Hold your breath for 10 seconds to allow the medication to reach your airways.
- Breathe out slowly.
- If you need another puff, wait 1 minute and repeat steps 4 to 8.
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