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 B

Explanation

Choice A reason: This posture, known as the tripod position, is common among clients with emphysema as it helps them breathe more easily by using accessory muscles. While it indicates respiratory distress, it is not immediately life-threatening.

Choice B reason: A respiratory rate of 8 breaths/min is significantly below the normal range (12-20 breaths/min) and indicates hypoventilation, which can lead to life-threatening conditions such as hypercapnia (elevated carbon dioxide levels in the blood). This finding needs immediate attention from the provider.

Choice C reason: A barrel chest is a common physical finding in clients with chronic emphysema. It develops over time due to hyperinflation of the lungs but is not an urgent finding that needs immediate reporting.

Choice D reason: Fine bibasilar crackles can indicate fluid accumulation in the lungs or other lung pathology, but this finding alone does not necessarily require immediate intervention unless accompanied by other critical symptoms.

A. Client reports having intermittent mild headaches. B. Client reports some erectile dysfunction. C. Client reports having dyspnea and chest pain. D. Client reports having elevated liver function tests.

Correct Answer is C

Explanation

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with a diagnosis of acute emphysema. The client is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which assessment findings should be reported to the provider immediately?

Correct Answer is B

Explanation

The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

Correct Answer is C

Explanation

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The nurse is teaching a class on bioterrorism. What is the scientific rationale for designating a specific area for decontamination?

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