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.

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Correct Answer is B

Explanation

A. This response acknowledges the parent's concern but maintains confidentiality regarding the report. It offers to involve the supervisor, which is a reasonable step. However, it may leave the parent feeling uneasy or uncertain.
B. This response directly informs the parent about the legal obligation of the nurse to report suspected child abuse. It provides clarity on why the nurse took action. However, it might be perceived as abrupt or lacking empathy.
C. This response suggests that someone else (possibly a healthcare provider or another authority figure) will explain the situation later. It doesn't directly address the reason for the nurse's action or the legal requirement to report.
D. This response explains the chain of events, from reporting to the supervisor's decision to contact authorities. It provides information but might not directly address the parent's emotional concern or the legal obligation of the nurse.

A. "Position the mask on your face with the flexible metal piece at the bottom." B. "Touch the front of your mask while wearing it." C. "Discard your mask after each use." D. "Remove your mask prior to removing your gloves."

Correct Answer is C

Explanation

A. The flexible metal piece in the medical mask is designed to be shaped around the nose to provide a better fit and seal. Placing it at the bottom is not appropriate.
B. It is important not to touch the front of the mask while wearing it, especially with potentially contaminated gloves or hands. Touching the front of the mask can transfer pathogens from the mask to the hands or vice versa, compromising infection control measures.
C. Medical masks are designed for single use and should be discarded after each use to prevent contamination and ensure effectiveness.
D. You should remove your gloves first before removing your mask to avoid contaminating your face with any pathogens that might be on the gloves.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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