A nurse is caring for a client who fell while walking to the bathroom. Which of the following actions should the nurse take when completing the incident report?

Choice A Reason:Using direct quotes from the client in the incident report is appropriate because it provides an accurate and objective account of the client's perspective. This is an important part of documenting the incident.

Choice B Reason:Incident reports are meant to be internal documents used for quality improvement and risk management. Noting in the medical record that an incident report was completed is not appropriate, as it could imply liability or affect the legal status of the report.

Choice C Reason:The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.

Choice D Reason:
The nurse should not draw conclusions about the cause of the incident in the incident report. The report should contain only objective facts, not assumptions or interpretations.

Choice A Reason:

Placing the drainage system below the client's chest level is appropriate. This positioning allows for proper drainage and prevents the backflow of fluid or air into the chest. Maintaining the drainage system below the chest level helps ensure effective evacuation of air or fluid from the pleural space.

Choice B Reason:

Looping excess tubing next to the client's side is inappropriate. Looping excess tubing can create dependent loops, potentially causing fluid to accumulate in these areas and compromising the drainage system's effectiveness.

Choice C Reason:

Clamping the tubing when ambulating the client is inappropriate. Chest tube drainage systems should not be routinely clamped during ambulation. Clamping can lead to increased pleural pressure, potentially causing tension pneumothorax or other complications.

Choice D Reason:

Milking the client's tubing every shift is inappropriate. Milking or stripping the tubing is not recommended, as it can create a pressure gradient that may damage the lung tissue or disrupt the chest tube's seal. Passive drainage is preferred to maintain the negative pressure in the system.