A nurse in a long-term care facility is completing an incident report for a client who received a superficial burn from a heating pad. Which of the following actions should the nurse take?
Document in the nurses' notes that an incident report was completed.
Record the facts about the incident in the medical record.
Provide the family with a copy of the incident report.
Place a copy of the incident report in the medical record.
The Correct Answer is B
A. Document in the nurses' notes that an incident report was completed:
This is incorrect. The incident report is an internal risk management tool and should not be mentioned in the medical record.
B. Record the facts about the incident in the medical record:
The nurse should document objective facts about the event, assessment, and interventions in the client’s medical record without referencing the incident report.
C. Provide the family with a copy of the incident report:
Incident reports are confidential and not shared with clients or families.
D. Place a copy of the incident report in the medical record:
This is incorrect; incident reports are kept separately from the medical record to avoid legal complications.
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Correct Answer is C
Explanation
A. Admission paperwork:
Admission paperwork is not essential for emergency transfer; it contains historical data that is less urgent for immediate care decisions.
B. Care plan:
While the care plan outlines ongoing interventions, it is less critical for emergency management during an acute event.
C. Medication administration record:
The MAR provides essential, up-to-date information about the client’s current medications, dosages, and administration times, which is critical for safe and accurate care in the receiving facility.
D. Discharge summary:
A discharge summary is completed at the end of a stay, not during an emergency transfer.
Correct Answer is B
Explanation
A. A client who has a dislocated shoulder:
This is painful and requires prompt care but is not as urgent as airway/breathing compromise.
B. A client who has audible wheezes:
Audible wheezing indicates airway narrowing or bronchospasm, which is a potential respiratory emergency and must be assessed and treated immediately.
C. A client who reports right lower-quadrant abdominal pain:
This could be appendicitis, which is urgent, but airway/breathing issues take precedence.
D. A client who has a 5 cm (2 in) laceration of the thigh:
This requires cleaning and closure but is less urgent than compromised breathing.
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