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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place the client on bed rest in supine position:
While bed rest might be appropriate for certain respiratory conditions, it is not a specific intervention for crackles. In fact, changing the client's position, such as having them sit up, may enhance lung function and help with breathing.
B. Repeat auscultation after asking the client to breathe deeply and cough:
This is the correct action. Repeating auscultation after having the client take deep breaths and cough can provide additional information about the nature of the crackles and may help clear the airways temporarily.
C. Prepare to administer antibiotics:
Administering antibiotics would be considered if the crackles are indicative of a respiratory infection. However, determining the need for antibiotics would require a more comprehensive assessment, including diagnostic tests.
D. Instruct the client to limit fluid intake to less than 2,000 mL/day:
Limiting fluid intake is not a direct intervention for crackles. This action is typically considered in conditions like heart failure where there is a risk of fluid overload. It is not the primary intervention for addressing crackles in the lungs.
Correct Answer is ["6"]
Explanation
To calculate the amount of ampicillin needed for one dose, we need to use a proportion. We can set up the proportion as follows:
150 mg / x mL = 125 mg / 5 mL
We can cross-multiply and solve for x:
150 * 5 = 125 * x
750 = 125 * x
x = 750 / 125
x = 6
Therefore, we need 6 mL of ampicillin for one dose
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