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 ["A","B","D","E"]
Explanation
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
Correct Answer is B
Explanation
Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.
a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.
c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.
d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.
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