A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation?
Document in nurse's notes, "Incident report completed and filed."
Document in nurse's notes, "Photocopy of incident report sent to risk management."
Document in incident report, "Client found lying on the floor after falling out of bed."
Document in incident report, "Entered room and discovered client lying prone on the floor.
The Correct Answer is D
A. "Incident report completed and filed" should not be documented in the client’s medical record. The incident report is for internal use only and should not be referenced in the chart.
B. "Photocopy of incident report sent to risk management" is also inappropriate for documentation in the medical record, as it exposes the facility to legal risk.
C. "Client found lying on the floor after falling out of bed" assumes the cause of the client’s position without direct observation, which could be inaccurate or speculative.
D. "Entered room and discovered client lying prone on the floor." – Yes. This is an objective, factual statement based on direct observation, which is appropriate for an incident report. It avoids assigning blame or making assumptions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A.An ankle injury with pain is painful but not life-threatening. This client can safely wait.
B.A 2 cm head laceration with dark red blood suggests venous bleeding and is not emergent unless signs of more serious head injury are present.
C.An older adult client with dyspnea and a respiratory rate of 26/minshould be examined first. Dyspnea (shortness of breath) and elevated respiratory rate indicate possible respiratory distress or a life-threatening condition such as pulmonary embolism, heart failure, or pneumonia. Airway and breathing issues always take priority.
D.Ecchymoses (bruising) could suggest a bleeding or clotting disorder but are not immediately life-threatening without other symptoms.
Correct Answer is D
Explanation
A. This specialized task is typically performed by trained technicians or registered nurses, not LPNs.
B. This is a detailed gestational age assessment requiring clinical judgment, which is outside the LPN’s scope of practice.
C.This task can be delegated to assistive personnel, not requiring LPN-level training.
D.Administering medications and vaccines is within the scope of practice for a licensed practical nurse (LPN)under the supervision of an RN or provider.
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