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 ["45"]

Explanation

To calculate the amount of potassium chloride (K-Dur) solution to administer, we need to use the following formula:

mL to administer = ordered dose (mEq) / available dose (mEq/mL) x mL

Plugging in the values from the question, we get:

mL to administer = 60 mEq / (20 mEq / 15 mL) x 15 mL

Simplifying the equation, we get:

mL to administer = 60 mEq x 15 mL / 20 mEq

mL to administer = 45 mL

Therefore, the nurse should administer 45 mL of potassium chloride (K-Dur) solution to the patient.

A. The client B. Progress note C. Medical history D. Family information

Correct Answer is A

Explanation

A. The client:

The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.

B. Progress note:

Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.

C. Medical history:

The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.

D. Family information:

Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ordered: Potassium chloride (K-Dur) 60 mEq Available: Potassium chloride (K-Dur) 20 mEq/15 mL Administer: _____mL

Correct Answer is ["45"]

Explanation

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Correct Answer is A

Explanation

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