A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take?
Use objective terminology when documenting
Wait at least 12 hours to report the occurrence
Omit the name of the individuals involved
Document completion of the report in the client’s medical record
The Correct Answer is A
Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The prodromal stage is the period between the exposure to the infectious agent and the onset of specific symptoms. During this stage, the person may experience mild and nonspecific signs of infection, such as fatigue or lowgrade fever. The client in the question has already developed specific symptoms of infection, such as sneezing, productive cough, and fever, which indicate that they have passed the prodromal stage.
Choice B reason: The period of convalescence is the stage of recovery after the infection. During this stage, the person's symptoms gradually subside, and their immune system eliminates the infectious agent from the body. The client in the question is still experiencing symptoms of infection, which suggest that they have not reached the period of convalescence yet.
Choice C reason: The acute illness stage is the peak of the infection, when the person exhibits the most severe and specific symptoms of the disease. During this stage, the person's immune system fights against the infectious agent, and the outcome of the infection is determined. The client in the question is likely in the acute illness stage, as they have been experiencing symptoms of infection for 4 days, and their condition has worsened over time.
Choice D reason: The incubation stage is the time between the entry of the infectious agent into the body and the appearance of the first symptoms of infection. During this stage, the person does not feel ill, but the infectious agent is multiplying in the body. The client in the question has already developed symptoms of infection, which indicate that they have left the incubation stage.
Correct Answer is A
Explanation
Choice A: This is the correct answer. A portal is a secure online platform that enables clients to access their health information, communicate with their providers, request appointments, refill prescriptions, and more. This enhances client satisfaction, engagement, and empowerment.
Choice B: This is incorrect. Same day access to client health record is not an advantage of electronic documentation, but a requirement for any documentation system. Clients have the right to access their health information within a reasonable time frame, regardless of whether it is paper-based or electronic.
Choice C: This is incorrect. The increase of duplicate tests performed on client is not an advantage of electronic documentation, but a disadvantage. Duplicate tests can result from poor communication, lack of interoperability, or human error. Electronic documentation can help reduce duplicate tests by facilitating data sharing, standardizing formats, and alerting providers of previous tests.
Choice D: This is incorrect. Decrease in coordination of client care is not an advantage of electronic documentation, but a disadvantage. Coordination of client care is essential for ensuring quality, safety, and continuity of care. Electronic documentation can improve coordination of client care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools.
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