A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?
Administer acetaminophen to the client.
Complete an incident report.
Send the visitor to the risk management office.
Document the occurrence in the client's medical record.
The Correct Answer is B
The correct answer is that the nurse should complete an incident report. An incident report is a formal record of an unexpected event that occurred in a healthcare facility. It is important for the nurse to document the details of the visitor's fall, including the date, time, location and any witnesses. This information can be used to identify and address any safety hazards that may have contributed to the fall.
Options a, c and d are not appropriate actions for the nurse to take in this situation. Administering acetaminophen to the client is not relevant to the visitor's fall. Sending the visitor to the risk management office and documenting the occurrence in the client's medical record are not necessary steps in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's statement that they will place the suppository as far inside their vagina as they can reach indicates an understanding of the teaching. This ensures that the medication is delivered to the site of infection.
a. The client should continue to use the medication for the full course of treatment, even if their symptoms improve before the treatment is complete.
b. The client can lie on their back or side to insert the suppository; there is no specific requirement to lie on their left side.
c. Lubricant is not typically necessary for the insertion of a vaginal suppository.
Correct Answer is C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
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