A nurse is caring for a 4-year-old child following an orthopaedic procedure. When assessing the child for pain, which of the following pain scales should the nurse use?

The nurse who caused the error is responsible for completing an incident report. An incident report is a tool for documenting any event that deviates from the standard of care or causes harm to a client, staff member, or visitor. The purpose of an incident report is to improve quality and safety, not to assign blame or punish anyone. The nurse who caused the error should fill out the report as soon as possible after the event, providing factual and objective information.

A. The quality improvement committee is not directly involved in the incident and does not complete the report. The committee may review the report later to identify trends and areas for improvement.

B. The charge nurse is not responsible for completing the report, although they may assist or supervise the nurse who caused the error.The charge nurse may also notify the provider and other relevant staff members about the incident.

C.The nurse who caused the error may be involved in providing details and information about the incident, but the nurse who discovers the error is the one responsible for completing the incident report to ensure that all relevant information is accurately documented.

D. It is crucial for the nurse who discovers the error to complete the incident report to ensure that all relevant details are accurately documented. This allows for a thorough investigation and implementation of corrective actions to prevent future errors.

This is because a weight gain of 2.5 kg (5 Ib) in 2 days indicates a worsening of heart failure and fluid retention, which may require an adjustment of the diuretic dose or other medications.

The provider should be informed of this change as soon as possible to prevent further complications.

Choice A is wrong because teaching the client about foods low in sodium is not the first action the nurse should take.

While a low-sodium diet is important for heart failure patients, it is not an urgent intervention and it does not address the immediate problem of fluid overload.

Choice B is wrong because determining medication adherence by the client is not the first action the nurse should take.

While it is important to assess if the client is taking furosemide as prescribed, it is not an urgent intervention and it does not rule out other causes of fluid retention, such as renal impairment or disease progression.

Choice C is wrong because encouraging the client to dangle the legs while sitting in a chair is not the first action the nurse should take.

While this may help reduce edema in the lower extremities, it does not address the underlying cause of fluid overload and it may worsen pulmonary congestion by increasing venous return to the heart.