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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Check temperature and SPO2

When the nurse finds an adult patient's pulse rate to be 140 beats per minute, it is important to assess other vital signs, particularly temperature and oxygen saturation (SPO2). This helps gather additional information to understand the overall clinical picture and assess for potential underlying causes of the elevated heart rate.

B. Report the rate to the primary care provider:

Reporting the heart rate to the primary care provider may be necessary, but it should not be the immediate action. Assessing other vital signs first provides a more comprehensive understanding.

C. Check the pulse again in 2 hours:

Waiting for 2 hours to recheck the pulse is not appropriate when the heart rate is significantly elevated. Immediate action and further assessment are needed.

D. Record the information:

Recording the elevated heart rate is part of documentation, but it should be accompanied by a more comprehensive assessment of vital signs and potential contributing factors.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?

Correct Answer is A

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

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

The nurse is surprised to detect an elevated temperature (102 °F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do?

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment, what finding would the nurse expect?

A nurse is caring for a client who has an electrical burn. With the client’s permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is? What is the appropriate response by the instructor?

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)