A client fell out of bed trying to go to the bathroom. The nurse has assessed the patient and no serious injuries were noted. What is the next best action of the nurse?
Document that the client fell.
Fill out an incident report if the client is actually injured.
Notify the healthcare provider.
Assist the client back to bed.
The Correct Answer is A
Choice A reason: Documentation of the fall is the most appropriate next step after assessing the patient and confirming no serious injuries. Falls are considered sentinel events in healthcare, and accurate documentation ensures continuity of care, supports risk management, and provides a legal record. Even if no injury occurred, the fall must be documented to monitor patterns and prevent future incidents.
Choice B reason: This option is incorrect because incident reports must be completed for all falls, regardless of whether the client is injured. Limiting reports to injured patients would omit important safety data and hinder quality improvement efforts.
Choice C reason: Notifying the healthcare provider is necessary if the client sustained injuries or if there are concerns about their condition. However, since no serious injuries were noted, immediate provider notification is not required. Documentation and monitoring are the priority.
Choice D reason: Assisting the client back to bed is appropriate for safety and comfort, but it is not the next best action after assessment. Documentation takes precedence to ensure the event is recorded and addressed within facility protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is correct because patients with C-Diff must be placed in contact isolation. C-Diff spores are highly contagious and can survive on surfaces for long periods. Contact isolation prevents transmission by requiring healthcare workers to use appropriate protective measures and limit exposure to other patients.
Choice B reason: This statement is correct because PPE should be discarded inside the patient’s room to prevent contamination of the hallway or other patient areas. Removing and disposing of PPE before leaving the room ensures that spores are contained and not spread throughout the facility.
Choice C reason: This statement indicates the student nurse needs further education. Alcohol-based hand sanitizers are ineffective against C-Diff spores. The correct practice is to wash hands thoroughly with soap and water after patient contact. Soap and water physically remove spores from the hands, whereas alcohol does not kill them. This misunderstanding could lead to the spread of infection.
Choice D reason: This statement is correct because wearing gloves and gowns when providing care is essential for preventing transmission of C-Diff. Spores can contaminate clothing and skin, so protective barriers are necessary to reduce the risk of spreading infection to other patients or surfaces.
Correct Answer is B
Explanation
Choice A reason: Putting on gloves before the gown is incorrect because gloves must cover the cuff of the gown to ensure a proper barrier.
Choice B reason: The correct sequence is gown first, then mask, then goggles or face shield, and finally gloves. This order ensures maximum protection and prevents contamination during patient care.
Choice C reason: Gloves should be donned last, not immediately after the gown. This option disrupts the protective sequence.
Choice D reason: Mask should not be donned before the gown. The gown establishes the primary barrier, followed by respiratory and eye protection, then gloves.
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