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."

Answer and Explanation

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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Correct Answer is A

Explanation

The correct answer is A. Clean the wound from the center to the outer edges.

Rationale: The nurse should clean the wound from the center to the outer edges to prevent contamination of the wound bed by bacteria or debris from the surrounding skin. The nurse should wear clean gloves, not sterile gloves, to remove the dressing, as wet-to-dry dressings are not sterile and do not require a sterile technique.

The nurse should remove the tape by pulling parallel to and away from the skin, not from the center of the dressing, to minimize skin damage and pain. The nurse should not moisten the dressing before removal, as this would defeat the purpose of wet-to-dry dressings, which are intended to debride necrotic tissue by adhering to it and pulling it off when dry.

A. Keep the finger in a dependent position. B. Wear sterile gloves. C. Select the central tip of a finger D. Test the first drop of blood that forms after the puncture.

Correct Answer is A

Explanation

A. Keep the finger in a dependent position:

Keeping the finger in a dependent position (lower than the heart) helps promote blood flow to the fingertips, making it easier to obtain a blood sample. This position can facilitate the formation of a blood drop, improving the chances of obtaining an adequate sample for testing.

B. Wear sterile gloves:

Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. Clean, non-sterile gloves are generally sufficient for this procedure. However, the nurse should perform proper hand hygiene to minimize the risk of contamination.

C. Select the central tip of a finger:

The central tip of the finger is more sensitive, and choosing this area may cause greater discomfort for the client. The sides of the fingertips are often preferred for capillary blood glucose testing as they have a good blood supply and are less sensitive.

D. Test the first drop of blood that forms after the puncture:

The initial drop may contain tissue fluid or contaminants from the puncture site, so it is important to use the first drop to obtain a representative blood sample. This step contributes to the accuracy of the blood glucose measurement.

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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?

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Correct Answer is A

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