A nurse is caring for a client who falls in his room. After the nurse assesses the client, notifies the client's provider, and completes an incident report, which of the following actions should the nurse take?
Make a copy of the incident report for the provider.
Submit the incident report to the risk manager.
Place the incident report in the client's chart.
Document in the chart that an incidence report has been filed.
The Correct Answer is B
Rationale:
A. Making a copy of the incident report for the provider is not necessary; the report should be handled according to the facility’s protocol.
B. Submitting the incident report to the risk manager ensures it is reviewed and addressed appropriately, which is crucial for risk management and quality improvement.
C. Placing the incident report in the client’s chart is not appropriate as it is considered a confidential document related to quality and safety, not part of the client’s medical record.
D. Documenting in the chart that an incident report has been filed is not sufficient; the report should be submitted to the risk management team for review.
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Correct Answer is A
Explanation
Rationale:
A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.
B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.
C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.
D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.
Correct Answer is A
Explanation
Rationale:
A. Diaphoretic with epigastric pain could be indicative of a myocardial infarction or other severe condition and requires immediate attention.
B. A toddler with a laceration and distress needs care but is not as urgent as potential cardiac issues.
C. An adolescent with slurred speech and belligerence could indicate a neurological issue, but is less immediate than a potential cardiac event.
D. A young adult with a sunburn is painful but not life-threatening compared to other scenarios.