An unlicensed assistive personnel (UAP) reports to the nurse that a client was found on the floor. Which action should the nurse do after ensuring the client's safety?
Document the event in the client's record only.
Document the event in the client's chart and file an incident report.
Document the event and have the UAP file an incident report.
File the incident report only.
The Correct Answer is B
Client safety events such as falls are managed through immediate assessment followed by accurate clinical documentation and formal incident reporting systems to support quality improvement, risk management, legal protection, and identification of preventable hazards within healthcare environments.
Rationale:
A. This action is incorrect because documenting only in the client record omits required incident reporting procedures. Falls require both clinical documentation and institutional reporting to ensure risk tracking and quality improvement measures are implemented appropriately.
B. This action is correct because it ensures both clinical documentation in the client’s health record and completion of an incident report, which is used for internal quality assurance and safety monitoring. Incident reports are not part of the medical record.
C. This action is incorrect because incident reports must be completed by the licensed nurse, not the UAP. Delegating incident reporting responsibility is inappropriate since it requires professional clinical judgment and accurate interpretation of the event context.
D. This action is incorrect because filing only an incident report fails to provide required documentation in the client’s medical record. Both documentation systems are necessary to ensure continuity of care, legal protection, and communication among healthcare providers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Failure to rescue reflects systemic inefficiency and clinical oversight where healthcare providers fail to recognize or act upon impending deterioration. This phenomenon correlates with mortality rates, emphasizing the necessity of early detection of physiological instability and rapid intervention to prevent adverse outcomes.
Rationale:
A. Delaying a smoking cessation consult is a missed opportunity for preventative health, but it does not constitute failure to rescue. Failure to rescue specifically refers to life-threatening clinical complications that occur while a patient is under professional medical supervision.
B. Failing to notify a provider about a high fever in a pneumonia patient illustrates clinical negligence. Ignoring signs of sepsis progression or worsening infection prevents timely intervention, directly leading to a failure to rescue from a potentially fatal condition.
C. Immediately assisting a client with chest pain and assessing hemodynamic status demonstrates competent clinical judgment. This proactive response facilitates early intervention, which is the exact opposite of failure to rescue, as the nurse actively manages the acute event.
D. While a fall indicates a lapse in safety protocols, reporting the incident and assessing the client after the fact is standard procedure. Failure to rescue typically involves missing clinical cues that lead to death or major permanent disability from complications.
Correct Answer is B
Explanation
Inhalation anthrax, caused by Bacillus anthracis spores, involves rapid germination in mediastinal lymph nodes leading to hemorrhagic mediastinitis and septicemia. It is not transmitted person-to-person; rather, it results from direct aerosolized spore inhalation or cutaneous exposure to infected animal products.
Rationale:
A. Respiratory precautions are not indicated because inhalation anthrax does not spread through large droplets from the oropharynx. While the initial symptoms mimic a viral prodrome, the bacteria remain localized within the mediastinum and blood rather than respiratory secretions.
B. Standard precautions are the clinical requirement for anthrax because the disease is not contagious between humans. Healthcare workers utilize gloves and gowns only if expecting contact with body fluids or open skin lesions, as direct transmission does not occur.
C. Contact precautions are unnecessary unless the patient has draining cutaneous anthrax lesions that could contaminate the environment. For inhalation cases, the spores are already internalized and do not pose a cross-contamination risk to staff through normal physical contact or fomites.
D. Airborne precautions are reserved for pathogens like Mycobacterium tuberculosis that travel via small-particle aerosols from coughing. Though anthrax spores are inhaled, the vegetative cells present during active infection are not shed into the air by the patient.
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