A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

The client attempted to climb over the side rails and fell

The client was restless and trying to get out of bed all evening

The presence of a bed alarm could have prevented the client from falling

The client was lying on the floor next to his bed

Answer and Explanation

The Correct Answer is D

A. The client attempted to climb over the side rails and fell:

This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.

B. The client was restless and trying to get out of bed all evening:

Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.

C. The presence of a bed alarm could have prevented the client from falling:

This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.

D. The client was lying on the floor next to his bed:

This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.

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Correct Answer is ["C","E"]

Explanation

A. Place the client in semi-Fowler’s position:

While the semi-Fowler's position can be helpful in assessing respiratory function, it is not specifically required for measuring the respiratory rate. The key is to ensure the client is comfortable and able to breathe easily.

B. Have the client rest an arm across the abdomen:

Placing the arm across the abdomen is not a standard practice for measuring respiratory rate. The key is to allow the client to breathe naturally, and this position is not necessary for accurate measurement.

C. Observe one full respiratory cycle before counting the rate:

This ensures that the count is accurate and reflective of the client's typical breathing pattern.

D. Count the rate for 30 seconds if it is irregular:

When measuring the respiratory rate, it is generally recommended to count for a full minute to obtain an accurate representation of the client's breathing pattern. Counting for 30 seconds may underestimate or overestimate the rate, especially if the irregularity is not consistent.

E. Count and report any sighs the client demonstrates:

Sighs can be indicative of emotional or physiological stress, and noting them is important for a comprehensive respiratory assessment.

A. Assess the client B. Notify the nurse manager C. Complete an incident report D. Call the client’s provider

Correct Answer is A

Explanation

A. Assess the client.

This is the immediate priority. The nurse should assess the patient's current condition to determine the extent of the impact of the error on the patient's health, focusing on respiratory status, vital signs, and signs of fluid overload.

B. Notify the nurse manager.

Once the patient has been assessed and stabilized, the nurse should inform the nurse manager or supervisor about the error. This helps ensure appropriate reporting, investigation, and follow-up actions.

C. Complete an incident report.

After assessing and stabilizing the patient, the nurse should document the error in an incident report. Incident reports are important for organizational learning, identifying patterns, and implementing improvements to prevent future errors.

D. Call the client’s provider.

If the patient's condition is deteriorating or requires immediate attention, the nurse should contact the healthcare provider to discuss the situation, report the error, and collaborate on necessary interventions.

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A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is instructing a group of nursing students in measuring a client’s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply)

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Explanation

Correct Answer is A

Explanation

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