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 B
Explanation
Choice A reason: Client's skin is pale and diaphoretic is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Choice B reason: Client reports chest pain after mowing lawn this morning is included in the subjective component. The subjective component records the data that the client verbalizes or expresses, such as symptoms, feelings, preferences, and beliefs.
Choice C reason: Client administered nitroglycerin 0.3 mg SL for chest pain is not included in the subjective component, but in the plan component. The plan component records the interventions and actions that the nurse implements or plans to implement for the client, such as medications, treatments, referrals, and education.
Choice D reason: Client's blood pressure is 182/98 mm Hg is not included in the subjective component, but in the objective component. The objective component records the measurable and observable data that the nurse collects from the client, such as vital signs, physical examination findings, and laboratory results.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect because a nurse’s personal values can and do influence ethical decisions. The nurse should be aware of their own values and how they affect their judgment and actions. The nurse should also respect the values of others and avoid imposing their own values on the clients or colleagues.
Choice B reason: This statement is incorrect because value clarification is not related to maintaining clinical competency. Value clarification is a process of identifying, examining, and prioritizing one’s values. It can help the nurse to understand their own values and beliefs, as well as those of the clients and the profession.
Choice C reason: This statement is correct because it is important that the nurse is aware of the client’s values. The nurse should assess the client’s values and preferences, and incorporate them into the plan of care. The nurse should also respect the client’s right to self-determination and autonomy, and support the client in making informed decisions.
Choice D reason: This statement is incorrect because a nurse's behaviors and actions are not called values. Values are the beliefs and principles that guide one’s decisions and actions. A nurse's behaviors and actions are the expressions of their values, as well as their knowledge, skills, and attitudes.
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