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. I should check my heart rate while taking this medication.

Rationale: Timolol is a beta-blocker that can lower intraocular pressure by reducing aqueous humor production in the eye. However, it can also cause systemic effects such as bradycardia, hypotension, and bronchospasm. Therefore, clients should monitor their heart rate and report any signs of adverse reactions to the provider. Zinc supplements, eye dilation, and eye color changes are not associated with timolol use.

A. Remove personal protective equipment after leaving the client’s room. B. Ensure that the negative air pressure is active for the client's room. C. Restrict the client's visitors D. Wear a gown when assisting the client with personal hygiene.

Correct Answer is D

Explanation

The correct answer is choice d. Wear a gown when assisting the client with personal hygiene. Choice A rationale: Removing personal protective equipment (PPE) after leaving the client’s room is incorrect. PPE should be removed before leaving the room to prevent the spread of MRSA to other areas. Choice B rationale: Ensuring that the negative air pressure is active for the client’s room is incorrect. Negative air pressure rooms are typically used for airborne infections, such as tuberculosis, not for MRSA, which is spread by contact. Choice C rationale: Restricting the client’s visitors is not necessary. Visitors should follow contact precautions, such as wearing gowns and gloves, but they do not need to be restricted. Choice D rationale: Wearing a gown when assisting the client with personal hygiene is correct. This helps prevent the spread of MRSA by protecting the nurse’s clothing and skin from contamination.

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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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