A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

The client attempted to climb over the side rails and fell

The client was restless and trying to get out of bed all evening

The presence of a bed alarm could have prevented the client from falling

The client was lying on the floor next to his bed

Answer and Explanation

The Correct Answer is D

A. The client attempted to climb over the side rails and fell:

This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.

B. The client was restless and trying to get out of bed all evening:

Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.

C. The presence of a bed alarm could have prevented the client from falling:

This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.

D. The client was lying on the floor next to his bed:

This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.

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Correct Answer is C

Explanation

A. Assess the pedal pulses with a Doppler device:

Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.

B. Assess the apical pulse with a Doppler device:

While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.

C. Assess the apical pulse for a full minute:

This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.

D. Assess the pedal pulses for a full minute:

While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.

A. Performs auscultation between meals B. Clamps the Naso Gastric tube during auscultation C. Palpates the abdomen prior to performing auscultation. D. Auscultates bowel sounds for 3 to 5 min

Correct Answer is C

Explanation

A. Performs auscultation between meals:

Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.

B. Clamps the Naso Gastric tube during auscultation

Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.

C. Palpates the abdomen prior to performing auscultation:

Palpating the abdomen before auscultation may interfere with normal bowel sounds

D. Auscultates bowel sounds for 3 to 5 min:

Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.

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A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client’s radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nursing instructor is observing a nursing student auscultating a client’s bowel sounds. Which of the following actions might require the instructor’s intervention?

Correct Answer is C

Explanation

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