The nurse responds to a voice calling out from a room on the nursing unit. Upon entering the room, the nurse sees a patient lying on the floor near the foot of the bed. After attending to the patient and notifying the HCP, which notation would be most appropriate to record on the incident occurrence report?

Patient found lying on floor at foot of the bed.

Patient was rushing to the bathroom to avoid incontinence.

Patient fell while walking to the bathroom.

Patient states nursing staff did not respond to the call bell.

Answer and Explanation

The Correct Answer is A

A.   This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B.   This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C.   Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D.   While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.

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Correct Answer is C

Explanation

A. While nurses can verify that a consent form is signed, they do not typically have the authority to ensure it is completed correctly or to explain the details of the procedure, which is the responsibility of the surgeon. The nurse's role is to ensure the client understands the procedure and has had the opportunity to ask questions, but they do not explain the surgery itself in detail.
B. This is a key responsibility of the nurse. Assessing the client's health status before surgery is critical for identifying any potential risks or issues that may affect the surgical outcome. This includes physical assessments and reviewing the client’s medical history.
C. This action is considered outside the nurse's responsibilities. The explanation of the operative procedure, risks, and benefits is typically the responsibility of the surgeon or the physician performing the surgery. Nurses may provide general information or support but are not the ones who explain the specifics of the surgical procedure.
D. Nurses are responsible for reviewing and interpreting preoperative laboratory results to ensure the client is medically ready for surgery. This review helps identify any abnormalities that may need to be addressed before proceeding with the surgical procedure.

A. worsening anemia B. vasoocclusive pain C. gastrointestinal upset D. itching/hives

Correct Answer is A

Explanation

A. This side effect, known as myelosuppression, is a significant concern and can manifest as anemia.
B. Hydroxyurea is actually prescribed to reduce the frequency of vasoocclusive crises by increasing fetal hemoglobin levels, which helps to prevent sickling of red blood cells. While a patient might experience pain crises while on hydroxyurea, the medication is intended to help manage this issue rather than be a reason for discontinuation.
C. While gastrointestinal upset is also a possible side effect, the risk of severe blood-related complications typically takes precedence when considering the discontinuation of hydroxyurea
D. While allergic reactions like itching or hives can occur with many medications, they are less common with hydroxyurea specifically.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Correct Answer is C

Explanation

What is the most likely reason a patient would discontinue their prescribed hydroxyurea?

Correct Answer is A

Explanation

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?(Select All that Apply.)

A nurse is uncharacteristically extroverted on today's shift, with an unsteady gait. The manager suspects that the nurse may be chemically Impaired. What is the manager's most appropriate action?

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

A registered nurse has been leading teams of nursing assistive personnel (NAP) for several years and will soon be leading licensed practical nurses (LPNs) for the first time. In preparation for delegating to these nurses, the RN should:

A nurse is reviewing information about the Health Insurance and Portability Act (HIPPA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Which statement is true regarding the general delegation liability of the registered nurse (RN)?

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?