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. Disinfecting blood pressure cuffs after clients are discharged. B. Demonstrating correct hand washing to the client's visitors." C. Asking clients about the use of immunosuppressant medications. D. Screening clients for upper respiratory tract symptoms.

Correct Answer is A

Explanation

A. Disinfecting equipment is a routine infection control measure that UAPs can perform after receiving proper training on the protocol. This activity does not require clinical judgment and falls within the
UAP’s responsibilities.
B. While UAPs may assist in educating visitors about hand hygiene, the demonstration of correct hand washing techniques is typically a nursing responsibility. Nurses are trained to provide this education effectively and ensure that the information is conveyed appropriately, especially since it may involve assessing visitors’ understanding.
C. This task requires clinical judgment and assessment skills, which are within the nursing scope of practice. Nurses need to evaluate this information in the context of the client’s overall health and care plan, making it inappropriate for delegation to UAP.
D. Screening for symptoms involves assessment and interpretation, which require a nursing level of knowledge and clinical judgment. While UAPs may collect basic data or report observations, actively screening clients for specific symptoms should be performed by a nurse.

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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

Which infection control activity should the nurse delegate to an experienced unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

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?

The RN overbears the nurses' aide speaking in a harsh tone to a client with early Alzheimer's memory loss. Which statement should the EN make to begin addressing this issue?

A nurse is caring for a client who has sickle cell anemia. The client asks. "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following health promotion strategies should the nurse include in the teaching?(Select All that Apply.)

Which term best describes sickle cell disease?