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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Incident reports are internal documents used within the hospital to record and analyze adverse events. They are not intended for direct reporting to state, local, and federal agencies, which have their own reporting mechanisms.
Choice B reason: While incident reports may indirectly contribute to assessing the effectiveness of interventions, their primary purpose is not to determine outcomes. Instead, they focus on documenting and analyzing incidents to prevent future occurrences.
Choice C reason: Providing necessary treatment to clients is the immediate response to an incident. However, the purpose of the incident report is broader—it aims to capture the details of the event for analysis and future prevention, not directly to ensure treatment.
Choice D reason: The primary purpose of an incident report is to help the institution identify risk situations and improve client care. By systematically documenting incidents, the hospital can analyze patterns, identify areas for improvement, and implement strategies to enhance safety and quality of care.
Correct Answer is B
Explanation
Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).
Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.
Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.
Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.