The nurse responds to a voice calling out from a room on the nursing unit. Upon entering the room, the nurse sees a patient lying on the floor near the foot of the bed. After attending to the patient and notifying the HCP, which notation would be most appropriate to record on the incident occurrence report?

Patient found lying on floor at foot of the bed.

Patient was rushing to the bathroom to avoid incontinence.

Patient fell while walking to the bathroom.

Patient states nursing staff did not respond to the call bell.

Answer and Explanation

The Correct Answer is A

A.   This statement is the most appropriate for an incident occurrence report. It provides a factual, objective description of what was observed without inferring causes or making assumptions about the patient’s actions. Clear documentation is critical in incident reports for accuracy and potential follow-up.
B.   This statement includes assumptions about the patient's motivations and actions. It is speculative and not based on direct observation. Incident reports should avoid subjective interpretations and focus on what can be objectively verified.
C.   Although this statement describes a potential scenario, it assumes that the patient was walking to the bathroom and that this was the cause of the fall. Since the nurse did not witness the event, this could be misleading and should be avoided in an incident report.
D.   While documenting patient statements can be important, this particular comment is subjective and does not provide an objective account of the incident. It could also lead to potential blame without verifying the accuracy of the statement, which could complicate the report.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. While nurses can verify that a consent form is signed, they do not typically have the authority to ensure it is completed correctly or to explain the details of the procedure, which is the responsibility of the surgeon. The nurse's role is to ensure the client understands the procedure and has had the opportunity to ask questions, but they do not explain the surgery itself in detail.
B. This is a key responsibility of the nurse. Assessing the client's health status before surgery is critical for identifying any potential risks or issues that may affect the surgical outcome. This includes physical assessments and reviewing the client’s medical history.
C. This action is considered outside the nurse's responsibilities. The explanation of the operative procedure, risks, and benefits is typically the responsibility of the surgeon or the physician performing the surgery. Nurses may provide general information or support but are not the ones who explain the specifics of the surgical procedure.
D. Nurses are responsible for reviewing and interpreting preoperative laboratory results to ensure the client is medically ready for surgery. This review helps identify any abnormalities that may need to be addressed before proceeding with the surgical procedure.

A. The integrity of the unit B. The nurse's personal growth C. The safety of clients and families D. The nurse's well-being

Correct Answer is C

Explanation

A. While maintaining the integrity of the unit is important, particularly concerning safety and professionalism, it should not be the primary focus in this scenario. Addressing the underlying issue of substance abuse is more crucial to ensure a safe environment for patients and staff.
B. Supporting the nurse's personal growth is important, especially in recovery. However, personal growth cannot be the primary concern when the nurse's behavior poses significant risks to patient safety. While this can be a component of the overall approach, it should not overshadow immediate safety concerns.
C. The safety of clients and families must be the top priority in this situation. The nurse’s substance abuse poses a direct risk to patient safety, and addressing this risk is essential. Ensuring that clients and families are safe should guide the manager's actions in handling the nurse's behavior.
D. The well-being of the nurse is certainly important and should be considered in the context of providing support and resources for recovery. However, in this case, the immediate risk to patients takes precedence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities?

Correct Answer is C

Explanation

A nurse-manager discovered that a nurse was retrieving narcotics from sharps containers and has been abusing these medications for several months. When addressing this behavior and assisting the nurse, what factor should the manager prioritize?

Correct Answer is C

Explanation

Which infection control activity should the nurse delegate to an experienced unlicensed assistive personnel (UAP)?

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?(Select All that Apply.)

The care of a client is assigned to a newly-graduated RN. What actions can the newly-graduated RN delegate to the unlicensed assistive personnel (UAP)? [SELECT ALL THAT APPLY]

A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?

A client with frequent watery stools and a possible Clostridium difficile infection is hospitalized with dehydration. Which nursing action should the charge nurse assign to an LPN?

What is the most likely reason a patient would discontinue their prescribed hydroxyurea?

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

A nurse is admitting a client who has sickle cell anemia. Which of the following manifestations should the nurse expect with this condition?(Select All that Apply.)