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. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.
B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.
C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.
D. Complete an incident report might be premature without understanding the reason behind the refusal.
Correct Answer is ["A","D"]
Explanation
Rationale:
A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.
B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.
C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.
D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.
E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.