A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?
Administer acetaminophen to the client.
Complete an incident report.
Send the visitor to the risk management office.
Document the occurrence in the client's medical record.
The Correct Answer is B
The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.
Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An ankle-foot orthotic can help prevent a plantar flexion contracture of the affected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.
a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.
b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.
d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.
Correct Answer is B
Explanation
When providing preoperative teaching to a client over the phone in preparation for outpatient surgery, the nurse should explain the need for the client to have another adult drive them home following surgery. This is because the client may still be affected by anesthesia and may not be able to safely operate a vehicle.
a. Asking the client to shower 3 times the day before surgery is not necessary and may dry out the skin.
c. The client should typically stop drinking clear liquids 2 hours before surgery, not 1 hour.
d. The client should not wear makeup during surgery as it can interfere with the monitoring of their skin color and oxygen saturation.
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