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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachycardia refers to a rapid heart rate, typically defined as a heart rate greater than 100 beats per minute. Theophylline can stimulate the heart and central nervous system, leading to an increase in heart rate. Tachycardia is a known adverse effect of theophylline and can occur especially if the medication is taken in higher doses or if there are interactions with other medications or caffeine.
B. Constipation is not a common adverse effect of theophylline. Theophylline primarily affects the respiratory and cardiovascular systems rather than the gastrointestinal system. Therefore, constipation is unlikely to be caused by theophylline therapy.
C. Drowsiness is generally not a common adverse effect of theophylline. Instead, theophylline is more likely to cause CNS stimulation, which can lead to insomnia, restlessness, or anxiety rather than drowsiness.
D. Oliguria refers to decreased urine output, which is not typically associated with theophylline use. Theophylline primarily affects respiratory function and cardiovascular parameters. Decreased urine output can occur in certain conditions or with medications that affect kidney function, but it is not a recognized adverse effect of theophylline.
Correct Answer is A
Explanation
A. An advance directive is a legal document that outlines a person's preferences for medical treatment, including end-of-life care. Asking the client if they have a copy of their advance directive is appropriate because it can provide valuable information about their wishes regarding medical interventions. It allows the nurse to review the document to ensure that the client's current wishes align with what is documented in their advance directive.
B. In most cases, a competent adult's healthcare decisions, including decisions to refuse treatment, are legally binding and cannot be overridden by family members. It is important for the nurse to educate the client about their rights and ensure that their wishes are respected. Family members may be involved in discussions and support the client's decisions, but they cannot override a competent adult's wishes regarding their medical care.
C. While it's important to involve family members in discussions about the client's wishes, especially if they are the client's designated healthcare proxy or legally authorized decision-maker, family agreement is not required for the client's decision to refuse life-saving measures. The nurse should primarily focus on the client's expressed wishes and ensure that these wishes are understood and respected.
D. The provider's agreement with the client's decision may be necessary to document and implement the plan of care accordingly, but ultimately, the decision to refuse treatment rests with the competent client. The nurse should facilitate communication between the client and the provider to ensure that the client's wishes are understood and documented appropriately.
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