A nurse in a long-term care facility is caring for a client who reports the assistive personnel repositioned him in bed using excessive force. Which of the following actions should the nurse take?
Contact the nurse manager.
Call risk management to interview the client.
Reassure the client that the staff is well trained.
Document in the client's chart that an incident report has been filed.
The Correct Answer is A
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Restraints should be applied based on a specific, documented need, not on an as- needed (PRN) basis, to ensure client safety.
B. A nurse can disclose information to a family member with the client's permission. This statement respects the client's right to privacy and confidentiality.
C. It is the responsibility of the doctor and not nurses to inform clients about available treatment options.
D. Administering medications without consent for research purposes is ethically unacceptable and violates the client's rights to autonomy and informed consent.
Correct Answer is B
Explanation
A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.
B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.
C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.
D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.
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