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 D

Explanation

Answer: D. Apply support stockings.

Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.

A. Collect a sterile specimen from the urinary drainage bag. B. Secure the tubing with adhesive tape to the lower abdomen. C. Instruct the client to hold the drainage bag at waist height when ambulating. D. Coil the tubing on the bed above the collection bag.

Correct Answer is B

Explanation

A.Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.

B.In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.

C.Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.

D.Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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