The nurse is caring for a hospitalized client who is found lying on the floor next to the bed. After completing the client assessment and notifying the provider, the nurse completes a hospital incident report. Which statements represent correct documentation that should be included in the report? (Select all that apply)

The client fell out of bed.

The client's vital signs are blood pressure 165/78, pulse 78, and respirations 16.

No bruises or injuries noted on the client.

The client apparently climbed over the side rails unwitnessed.

The health care provider was notified that the client was found on the floor next to the bed.

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: The statement "The client fell out of bed" is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions. Therefore, this statement should not be included in the incident report.

Choice B reason: Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.

Choice C reason: Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.

Choice D reason: The statement "The client apparently climbed over the side rails unwitnessed" includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.

Choice E reason: Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Including client information on the disaster tag is crucial for identification and tracking purposes. This information ensures that each client can be accurately identified, which is essential for providing appropriate care and for communication with family members and other healthcare providers.

Choice B reason: Triage priority is an essential piece of information that indicates the level of urgency for each client's care. This prioritization helps healthcare providers quickly identify which clients need immediate attention and which can wait, thereby optimizing the use of limited resources during a mass casualty incident.

Choice C reason: Next of kin information is important for contacting family members and loved ones in case of emergency. This information is essential for communicating the client's status, obtaining additional medical history, and providing support to the family during a stressful time.

Choice D reason: Decontamination information, if applicable, indicates whether the client has undergone decontamination procedures. This is critical for ensuring that contaminated clients do not pose a risk to others, including healthcare providers and other patients, and for maintaining a safe environment within the healthcare facility.

Choice E reason: Documenting medications and treatments administered is vital for continuity of care. This information allows healthcare providers to track what treatments have been given, avoid duplication of medications, and monitor the client's response to treatment. It also ensures that any subsequent healthcare providers have a complete record of the client's care.

A. The acuity level of the clients. B. The clustering of the rooms on the unit. C. Client needs and the staff's needs and abilities. D. The number of anticipated client discharges. E. Specific requests from the staff.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: The acuity level of the clients is a critical factor to consider when planning staff assignments. Clients with higher acuity levels require more intensive care and monitoring, necessitating a greater allocation of resources and experienced staff. By considering client acuity, the charge nurse can ensure that the most critical patients receive the appropriate level of care and attention, while also balancing the workload among the nursing staff.

Choice B reason: The clustering of the rooms on the unit can significantly impact the efficiency of care delivery. By grouping clients in close proximity, the nurse can minimize the time and effort spent moving between rooms, thus enhancing the ability to respond quickly to client needs. This consideration helps to optimize workflow and improve overall patient care by reducing potential delays.

Choice C reason: Considering both client needs and the staff's needs and abilities ensures that the right personnel are assigned to the appropriate tasks. Matching staff competencies with client requirements maximizes the effectiveness of care delivery. Additionally, taking into account staff preferences and skills can improve job satisfaction and performance, ultimately benefiting the clients.

Choice D reason: The number of anticipated client discharges is an important logistical factor that can affect the day's workflow. Planning for discharges allows the charge nurse to allocate resources for discharge planning, patient education, and follow-up care. It also helps in managing bed availability and preparing for incoming admissions, ensuring a smooth transition for both clients and staff.

Choice E reason: Specific requests from the staff can include preferences for certain shifts, working with particular patients, or avoiding specific tasks. While it may not always be possible to accommodate all requests, considering them when feasible can improve staff morale and cooperation. Addressing staff preferences helps to create a positive work environment, leading to better teamwork and patient outcomes.

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Naxlex Comprehensive Predictor Exams

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

The nurse working on a medical-surgical unit finds a client lying on their bathroom floor. After assessing the client and notifying the provider and nursing supervisor, the nurse completes a hospital incident report. What is the purpose of completing the hospital incident report?

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?

The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?