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","C","E"]
Explanation
A. This disease is caused by the varicella-zoster virus and is transmitted via airborne particles. When an infected person coughs or sneezes, the virus can be inhaled by others.
B. This bacterium causes severe diarrhea and colitis. It is primarily transmitted through contact with contaminated surfaces or feces, not through the air.
C. Measles is a highly contagious viral disease that spreads through airborne transmission. The virus can linger in the air for up to two hours after an infected person coughs or sneezes.
D. This bacterium can cause various infections, including skin infections and pneumonia. It is mainly spread through direct contact with an infected person or contaminated surfaces, not through the air.
E. Caused by the bacterium Mycobacterium tuberculosis, TB is transmitted through airborne particles. When a person with active TB coughs, sneezes, or talks, the bacteria can be inhaled by others.
Correct Answer is ["A","D","E"]
Explanation
A. Tachycardia, or increased heart rate, can occur during hypoglycemia as a result of the body's response to low blood sugar levels. The sympathetic nervous system is activated, leading to increased adrenaline (epinephrine) release, which can cause palpitations and tachycardia.
B. Polydipsia refers to excessive thirst. It is typically a symptom of hyperglycemia (high blood sugar levels) rather than hypoglycemia. During hypoglycemia, thirst is not a common symptom.
C. Polyuria refers to excessive urination. Similar to polydipsia, it is more commonly associated with hyperglycemia (high blood sugar levels) rather than hypoglycemia. Hypoglycemia typically does not cause polyuria.
D. Blurred vision can occur during hypoglycemia due to changes in the shape of the lens in the eye caused by altered fluid balance due to low blood sugar levels.
E. Moist, clammy skin is a common manifestation of hypoglycemia. When blood sugar levels drop, the body's autonomic nervous system responds by releasing adrenaline, which can cause sweating and clamminess.
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