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."

Answer and Explanation

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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Correct Answer is ["A","B","C","F","G","I","J"]

Explanation

A.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2.This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

B.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C.The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

D.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

E.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

F.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

G.The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.

H.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

I.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

J.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.

A. "Fidelity involves ensuring that we do no harm to the client." B. "Fidelity involves making sure clients are able to make their own health care decisions." C. "Fidelity involves keeping promises made to clients." D. "Fidelity involves treating every client with the same level of respect."

Correct Answer is C

Explanation

The correct answer is C. "Fidelity involves keeping promises made to clients." The rationale for this statement is that fidelity is a principle of ethics that requires nurses to be faithful, loyal, and trustworthy to their clients. Fidelity means that nurses should honor their commitments and obligations to their clients, such as following through with care plans, respecting confidentiality, and being honest. Fidelity also implies that nurses should advocate for their client's best interests and protect them from harm.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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