A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
Wait at least 12 hours to report the occurrence
Omit the name of the individuals involved
Document completion of the report in the client’s medical record
The Correct Answer is A
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A sentinel event is a serious adverse event that results in death, permanent harm, or severe temporary harm to a patient. Administering incompatible blood products to a client is a sentinel event because it can cause fatal hemolytic reactions.
Choice B reason: Administering client medications 30 minutes late is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Medication errors are common and preventable, and they should be reported and analyzed to improve patient safety.
Choice C reason: Documenting vital signs at the wrong time in the client’s electronic health record is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Documentation errors are also common and preventable, and they should be corrected and avoided to ensure accurate and timely information.
Choice D reason: Administering a prescribed sedative to a client for insomnia is not a sentinel event, unless it leads to a serious adverse outcome for the patient. Sedatives are commonly used to treat insomnia, and they should be prescribed and administered with caution and monitoring⁵.
Correct Answer is D
Explanation
Choice A reason: Eddie Bernice Johnson is not the founder of the American Red Cross, but rather a contemporary politician and nurse. She is the first registered nurse elected to the United States Congress, where she represents Texas's 30th congressional district.
Choice B reason: Florence Nightingale is not the founder of the American Red Cross, but rather the founder of modern nursing. She is known for her pioneering work in nursing education, research, and reform, especially during the Crimean War, where she improved the sanitary conditions and reduced the mortality rate of wounded soldiers.
Choice C reason: Dorothea Dix is not the founder of the American Red Cross, but rather a social reformer and advocate for the mentally ill. She is known for her efforts to improve the treatment and care of the mentally ill in the United States and Europe, and for organizing nurses during the American Civil War.
Choice D reason: Clara Barton is the founder of the American Red Cross, as well as a nurse and humanitarian. She is known for her service as a nurse during the American Civil War, where she tended to the wounded on the battlefield and distributed supplies. She also founded the American Red Cross in 1881, after learning of the International Red Cross in Switzerland, and led the organization for 23 years.
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