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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While prioritizing tasks is important, simply instructing the team member to focus on the most necessary tasks does not address the root of the problem. It may not provide the support or resources needed to effectively manage their workload.
B. While this might seem helpful in the short term, it does not empower the team member or address the issue of workload management. Taking on too much responsibility can also lead to burnout for the RN and is not a sustainable solution.
C. This option does not consider the needs of the original team member and may disrupt teamwork or create additional stress for other staff. It’s important to address the workload collaboratively rather than simply redistributing it without context.
D. This is the best initial action. By examining the workload together, the RN can help the team member identify which tasks are most critical and which can be deferred or delegated. This approach fosters collaboration, empowers the team member, and ensures that patient care needs are met efficiently.
Correct Answer is ["A","B","D"]
Explanation
A. This task is appropriate for UAP to perform, as it involves basic hygiene and does not require nursing judgment or clinical assessment. UAP can assist with routine oral care under the direction of the RN.
B. Assisting with position changes is a basic care activity that UAP can perform. This task helps prevent pressure ulcers and maintains client comfort, and it does not require the clinical judgment of a nurse.
C. Administering IV medications or fluids is a nursing task that requires specific training and knowledge of nursing assessments, potential complications, and monitoring. This task should only be performed by a licensed nurse, not by UAP.
D. UAP can document basic measurements such as urine output, as this is a straightforward task that does not require clinical judgment. However, the RN should ensure that the UAP understands how to accurately measure and record this information.
E. While UAP can observe and report general changes, monitoring for clinical indications of dehydration requires nursing assessment skills and judgment. This task should be performed by an RN.
F. While UAP can weigh clients, the assessment of weight trends requires clinical judgment and interpretation of data, which falls under the responsibilities of a licensed nurse. The RN should evaluate and interpret the data regarding the client's health status.
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