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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because low pain tolerance is not the most urgent issue to address. The client may experience some pain and discomfort after the surgery, but this can be managed with medication and non-pharmacological interventions. The nurse should educate the client on how to use pain scales, request pain relief, and apply ice packs or heat pads as needed.
Choice B reason: This is not the correct choice because decreased self-esteem is not the most urgent issue to address. The client may have some negative feelings about their appearance or abilities after the surgery, but this can be improved with counseling and support groups. The nurse should encourage the client to express their emotions, focus on their strengths, and seek professional help if necessary.
Choice C reason: This is not the correct choice because limited social support is not the most urgent issue to address. The client may have difficulty coping with the recovery process and the lifestyle changes required after the surgery, but this can be alleviated with community resources and referrals. The nurse should assess the client's social network, provide information on local agencies and organizations, and arrange for home health care or visiting nurses if needed.
Choice D reason: This is the correct choice because inadequate food supply is the most urgent issue to address. The client needs to have access to nutritious and balanced meals to promote healing and prevent complications after the surgery. The nurse should evaluate the client's food security, provide food vouchers or coupons, and connect the client with food banks or meal delivery services.
Correct Answer is D
Explanation
Choice A reason: A living will does not provide protection against malpractice. It is a legal document that expresses the client's wishes regarding medical care in the event of a terminal illness or injury.
Choice B reason: A living will does not designate a health care surrogate to make health care decisions. A health care surrogate is a person who is authorized by the client or the court to make health care decisions for the client when the client is unable to do so.
Choice C reason: A living will does not document that the client gave informed consent. Informed consent is the process of obtaining the client's voluntary agreement to a proposed treatment or procedure after providing adequate information about the benefits, risks, and alternatives.
Choice D reason: A living will allows the client to refuse life-sustaining treatments. This is the main purpose of a living will, as it gives the client the right to self-determination and autonomy over their own body and health.
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