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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While RNs can be held liable for their actions and, to some extent, for the actions of those they delegate to, liability is not automatic for all tasks delegated. Liability depends on whether the RN acted appropriately in the delegation process and whether the delegated tasks were performed within the subordinate's scope of practice.
B. While subordinates are accountable for their actions, RNs also share responsibility when they delegate tasks. If the RN delegates a task inappropriately or fails to supervise adequately, they may still be held liable for any resulting harm.
C. This statement is true. When RNs delegate tasks appropriately, ensuring that they are within the subordinate's scope of practice and providing adequate supervision, their liability is reduced. Proper delegation includes assessing the situation, providing clear instructions, and monitoring the outcomes.
D. While delegating to licensed personnel may reduce some liability, it does not eliminate it entirely. RNs still have a duty to ensure that the tasks delegated are appropriate for the individual’s scope of practice and to provide supervision.
Correct Answer is C
Explanation
A. While low ferritin levels can indicate iron deficiency anemia, sickle cell anemia primarily involves the production of abnormal hemoglobin rather than iron deficiency. Fatigue in sickle cell anemia is more closely related to the effects of the disease itself, including chronic hemolysis and decreased red blood cell survival.
B. Sickle cell anemia is not classified as an autoimmune disease; it is a genetic disorder caused by a mutation in the hemoglobin gene. While individuals with sickle cell anemia may have increased susceptibility to infections, the fatigue they experience is not due to an autoimmune process.
C. Sickle cell anemia leads to chronic hemolytic anemia, meaning the abnormal sickle-shaped red blood cells break down more quickly than normal red blood cells. This results in a lower overall red blood cell count (anemia), which can cause fatigue and weakness due to reduced oxygen-carrying capacity in the blood.
D. While gastrointestinal bleeding can lead to fatigue due to blood loss and subsequent anemia, it is not a direct consequence of sickle cell anemia. If the client had experienced a gastrointestinal bleed, it would typically need to be evaluated independently of their sickle cell disease.
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