A nurse is caring for a client who has fallen while getting out of bed and states, “I’m okay! I guess I should have called for help to the bathroom.” After assessing the client, the nurse notifies the provider.

Which of the following documentation should the nurse include in the client’s medical record?

An incident report was completed

There were no injuries sustained

The provider was notified

An incident report was forwarded to risk management

Answer and Explanation

The Correct Answer is C

Correct Answer: C

C. The provider was notified. The nurse should document objective facts, such as notifying the provider, in the client’s medical record. This ensures accurate communication about the client's condition and the steps taken after the fall.

Incorrect answers:

A. "An incident report was completed." The completion of an incident report should not be documented in the medical record. Incident reports are internal documents used for quality improvement and risk management, and mentioning them in the medical record could make them discoverable in legal proceedings.

B. "There were no injuries sustained." While documenting the client’s physical condition is appropriate, stating "no injuries sustained" might be premature or subjective. Instead, the nurse should record specific observations, such as "client denies pain" or "no visible signs of injury noted."

D. "An incident report was forwarded to risk management. Referencing the incident report in the medical record is inappropriate. Incident reports are separate from the client’s medical record and should not be mentioned in the documentation.

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Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

A. Documentation is a communication tool for the interprofessional health care team B. Documentation allows providers to monitor the nurse’s activities C. Documentation provides information to the client about financial charges. D. Documentation provides information for a client audit

Correct Answer is A

Explanation

A. Documentation is a communication tool for the interprofessional health care team

The purpose of documentation in the electronic health record (EHR) includes serving as a communication tool among members of the interprofessional healthcare team. Accurate and timely documentation allows healthcare providers to share information about the client's care, treatment, and outcomes.

B. Documentation allows providers to monitor the nurse’s activities:

While documentation provides a record of the nurse's activities, the primary purpose is to communicate information about patient care rather than serving as a tool for monitoring the nurse's activities.

C. Documentation provides information to the client about financial charges:

The primary purpose of documentation is to record and communicate information about the client's health status, care, and outcomes. Financial information is typically managed separately from clinical documentation.

D. Documentation provides information for a client audit:

While documentation can be used in audits for quality assurance, the primary purpose is to record and communicate information about patient care. The use of documentation for audits is a secondary function related to quality improvement and regulatory compliance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

A nurse is orienting a newly licensed nurse about documentation of a client’s information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

Correct Answer is A

Explanation

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

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A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

A nurse performs an integumentary assessment of a client who has recently fallen and broken his leg. The nurse notes the skin coloring on the broken leg is bluish gray. What is the term for this change in skin color?