A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take?

Document the completion of an occurrence report in the client's medical record.

Notify the client's provider about the occurrence.

Request another nurse to complete the occurrence report.

Contact risk management about the occurrence.

Answer and Explanation

The Correct Answer is B

A.   An occurrence report, also known as an incident report, documents the details of any unexpected event that occurs during the client's care. This includes falls. It is important to document the incident accurately and promptly in the client's medical record to ensure that all relevant information is recorded. However, this should not take priority over timely escalation of the issue.
B.   It is essential to notify the client's healthcare provider (such as the physician or nurse practitioner) about the fall incident. The provider needs to be informed about the client's condition after the fall, any injuries sustained, and any immediate actions taken.
C.   The nurse who witnessed or discovered the fall incident is responsible for completing the occurrence report. It should be filled out by the nurse who directly assessed the client's condition after the fall, documented any injuries, and initiated appropriate interventions. Asking another nurse to complete the report may not accurately reflect the details and actions taken by the nurse who was directly involved.
D.   Risk management may need to be informed about the fall incident, especially if it resulted in injury to the client. Risk management is responsible for assessing the circumstances surrounding the fall, identifying potential risks or contributing factors, and implementing strategies to prevent future incidents. However, contacting risk management is typically done after initial actions such as ensuring client safety, notifying the provider, and documenting the incident.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

A. Intimate partner violence (IPV) disproportionately affects certain populations, including women and marginalized groups. By routinely screening clients for IPV, nurses can identify those at risk and provide appropriate support, referrals to resources, and interventions. Addressing IPV can improve health outcomes by addressing physical and mental health consequences of abuse.
B. School performance can be influenced by various social determinants of health, including socioeconomic status, access to healthcare, and family dynamics. Inquiring about school performance allows nurses to identify potential issues affecting children's health and well-being. This information can guide referrals to educational resources, social services, or healthcare interventions to support children's academic success and overall health.
C. Older adults living in assisted living facilities can be vulnerable to neglect, abuse, or inadequate care. Assuming safety without assessment can overlook potential health disparities and risks faced by older adults. Nurses should routinely assess the living conditions, social supports, and healthcare needs of older adult clients to ensure they receive appropriate care and support, thus reducing disparities in care.
D. Gun violence disproportionately affects certain populations, including youth, minority communities, and those living in high-crime areas. Providing gun safety information upon request can help individuals make informed decisions about firearm ownership, storage, and safety practices. This education can contribute to reducing injuries and deaths related to firearms, thereby addressing disparities in injury prevention and public health.
E. Parenting support is crucial for promoting healthy child development and reducing disparities in children's health outcomes. Parents facing socioeconomic challenges, lack of access to resources, or social stressors may benefit significantly from parenting support. Providing information and resources in the emergency department can empower parents to navigate challenges effectively, enhancing their ability to provide a nurturing environment for their children.

A. The client's voice is hoarse. B. tingling around the mouth C. temperature has increased in 1 hr from 37.5° C (99.5° F) to 38.6° C (101.5° F) D. Moderate serosanguinous drainage noted on neck dressing E. Oxygen saturation 95% F. The client appears restless.

Correct Answer is ["A","B","C","D"]

Explanation

Correct choices are:

Hoarse voice

A hoarse voice can indicate injury or irritation to the recurrent laryngeal nerve, which is a common complication following thyroid surgery. This nerve is located near the thyroid gland and can be affected during thyroidectomy, leading to vocal cord dysfunction. It's important to report this change in voice to the provider for further evaluation and management.

Tingling around the mouth

Tingling around the mouth can be a sign of hypocalcemia, which is a potential complication after thyroidectomy due to inadvertent damage or removal of the parathyroid glands. These glands regulate calcium levels in the body. Hypocalcemia can present with symptoms such as tingling, numbness, and muscle spasms. Prompt reporting is necessary so that calcium levels can be assessed and appropriate treatment initiated if needed.

Temperature increase from 37.5°C (99.5°F) to 38.6°C (101.5°F) within 1 hour

A rapid increase in temperature postoperatively may indicate infection, such as surgical site infection or systemic infection. This is particularly concerning given the recent surgical procedure. Reporting this change in temperature promptly allows the provider to assess for signs of infection, order appropriate diagnostic tests (such as blood cultures or wound cultures), and initiate timely treatment.

Moderate serosanguinous drainage noted on neck dressing

Serosanguinous drainage (clear to slightly bloody fluid) on the neck dressing is expected post- thyroidectomy, but the amount and nature of drainage should be assessed regularly for any signs of excessive bleeding or infection. Reporting moderate drainage ensures that the provider can assess for complications, such as hematoma formation or wound infection, and intervene as necessary.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse should identify which of the following as ways to make a positive impact in reducing health disparities in the clients they care for?

Correct Answer is ["A","B","D","E"]

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

A nurse in a community health clinic is explaining to staff members that a mutation of influenza has increased the communicability of the virus. Which of the following information should the nurse include to describe the effect of communicability of a virus?

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

A nurse is admitting a client who requests not to be intubated or have any other life saving measures initiated. Which of the following actions should the nurse take?

A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include?

A school nurse receives a telephone call from a parent who suspects their school-age child may have coronavirus-2 (SARS-COV-2). Which of the following instructions should the nurse give as secondary prevention?

A nurse is assessing a client who has a long history of smoking and suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)