A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?
Sends the incident report to the ethics committee
Lists names of witnesses to the fall in the nurses' notes
Includes the client's account of the fall in the incident report
Documents in the client's record that an incident report was filed
The Correct Answer is C
Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.
Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.
Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.
Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the least urgent and most stable condition. A deep-vein thrombosis is a blood clot that forms in a vein, usually in the leg. An INR of 2.0 indicates that the client's blood is within the therapeutic range for anticoagulation therapy, which prevents the clot from growing or breaking off. The nurse should ensure that the client has a prescription for oral anticoagulants, compression stockings, and follow-up appointments before discharging them.
Choice B reason: This is not the correct choice because this client has a serious and potentially life-threatening condition. Tumor lysis syndrome is a complication of chemotherapy that occurs when cancer cells break down rapidly and release their contents into the bloodstream. This can cause electrolyte imbalances, kidney damage, and cardiac arrhythmias. The nurse should monitor the client's vital signs, laboratory values, urine output, and fluid balance, and administer medications and interventions as prescribed.
Choice C reason: This is not the correct choice because this client has a new and acute condition. A new onset of left-sided weakness could indicate a stroke, which is a medical emergency that requires immediate diagnosis and treatment. The nurse should perform a neurological assessment, check the client's blood pressure and blood glucose levels, and activate the stroke protocol.
Choice D reason: This is not the correct choice because this client has a severe and unstable condition. Angina is chest pain that occurs when the heart muscle does not get enough oxygen-rich blood. A troponin level of 3 ng/mL indicates that the client has a high level of cardiac enzymes in the blood, which suggests a heart attack or myocardial infarction. The nurse should administer oxygen, nitroglycerin, aspirin, and morphine as prescribed, and prepare the client for further diagnostic tests and interventions.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because an evidence-based nursing journal is a reliable and credible source of information that is based on research and best practices. A nurse can use an evidence-based nursing journal to find current and accurate data on the prevalence of Tay-Sachs disease, as well as the causes, symptoms, diagnosis, treatment, and prevention of the disease.
Choice B reason: This is not the correct choice because the client's health care provider is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The nurse should respect the client's autonomy and privacy and not contact the client's health care provider without the client's consent. The nurse should also avoid relying on the health care provider's opinion or knowledge, which may not be up to date or consistent with the evidence.
Choice C reason: This is not the correct choice because the facility's case manager is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. The case manager's role is to coordinate the client's care and services, not to provide information or education on specific diseases. The case manager may not have the expertise or the access to the relevant information that the nurse needs.
Choice D reason: This is not the correct choice because a collaborative, user-edited website is not a resource that the nurse should use to obtain information about the prevalence of Tay-Sachs disease. A collaborative, user-edited website, such as Wikipedia, is not a reliable or credible source of information, as anyone can edit or add content without verification or peer review. The information on such a website may be outdated, inaccurate, biased, or incomplete.
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