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: This statement belongs to the recommendation component, as it describes an action that the nurse has taken or suggests to take regarding the client's care.
Choice B reason: This statement also belongs to the recommendation component, as it expresses a need or a request for the client's treatment.
Choice C reason: This statement belongs to the situation component, as it summarizes the current problem or issue that the client is facing.
Choice D reason: This statement belongs to the background component, as it provides relevant information about the client's medical history or diagnosis.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because protecting a client’s personal health information is not an example of client advocacy, but a legal and ethical obligation of the nurse. The nurse should follow the principles of confidentiality and privacy, and only share the client’s information with authorized persons or entities, or with the client’s consent.
Choice B reason: This statement is incorrect because keeping a promise to return to a client’s room is not an example of client advocacy, but a professional and courteous behavior of the nurse. The nurse should be honest, reliable, and respectful to the client, and follow through with their commitments and expectations.
Choice C reason: This statement is incorrect because accepting responsibility for their own actions is not an example of client advocacy, but a personal and professional accountability of the nurse. The nurse should be aware of their scope of practice, standards of care, and code of ethics, and act accordingly. The nurse should also admit their mistakes, report errors, and seek help when needed.
Choice D reason: This statement is correct because communicating a client’s wishes to their provider is an example of client advocacy. The nurse should act as a liaison between the client and the provider, and ensure that the client’s needs, preferences, and values are respected and considered in the decision-making process. The nurse should also support the client’s right to self-determination and informed consent.
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