A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
The client fell because the assistive personnel did not place nonskid slippers on the client."
The client does not appear to have any injuries resulting from the fall."
"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
"An incident report has been completed and sent to risk management."
The Correct Answer is C
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The statement is correct because chickenpox is highly contagious, and visiting someone with active chickenpox can put the pregnant individual at risk of contracting the infection. The recommendation is to avoid contact with individuals who have chickenpox, especially during pregnancy. The correct approach is to stay away from the infected person until they are no longer contagious (which is usually after all the sores have crusted over and dried up).
Choice B reason:
The statement Is incorrect because taking antibiotics for a viral infection is not appropriate, as antibiotics are only effective against bacterial infections, not viruses. Using antibiotics inappropriately can lead to antibiotic resistance and other potential side effects. Viral infections are generally managed with supportive care.
Choice C reason:
The statement is incorrect because handwashing is an essential infection prevention measure, but washing hands for 10 seconds with hot water may not be sufficient to remove germs effectively. The recommended duration for handwashing is at least 20 seconds with soap and water.
Choice D reason:
The statement is incorrect because cleaning a cat's litter box during pregnancy is not recommended due to the potential risk of exposure to the parasite Toxoplasma gondii, which is found in cat faeces. Toxoplasmosis can cause serious health issues in the developing foetus. It is best for pregnant individuals to avoid cleaning the litter box and have someone else do it or wear gloves and wash hands thoroughly afterward if no one else can do it.
Correct Answer is ["A","D","E"]
Explanation
Urine output: At 1400, the client had oliguria (20 mL/hr). Magnesium is primarily excreted by the kidneys; if urine output is low, magnesium levels can rise to toxic levels. An increase to 40 mL/hr (exceeding the standard minimum threshold of 30 mL/hr) indicates improved renal perfusion and the body's ability to clear the magnesium, reversing the toxicity.
Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.
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