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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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
Correct Answer is C
Explanation
A. Assess the pedal pulses with a Doppler device:
Assessing the pedal pulses with a Doppler device may be useful in certain situations, but when the radial pulse is irregular, it's more important to assess the central (apical) pulse to get a more accurate representation of the heart's rhythm.
B. Assess the apical pulse with a Doppler device:
While using a Doppler device on the apical pulse is an option, it's generally not the first choice when assessing irregular pulses. The apical pulse can often be palpated manually, and it's more practical to assess it directly for irregularities.
C. Assess the apical pulse for a full minute:
This is the recommended action when the radial pulse is irregular. By assessing the apical pulse for a full minute, the nurse can accurately determine the heart rate and identify any irregularities in rhythm, providing a comprehensive assessment of the cardiac status.
D. Assess the pedal pulses for a full minute:
While assessing the pedal pulses is important in certain situations, it may not be the priority when dealing with an irregular radial pulse. Assessing the apical pulse for a full minute gives a more direct and accurate reflection of the heart's rhythm.
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