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 C
Explanation
Rationale:
A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.
B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.
C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.
D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.
Correct Answer is C
Explanation
Rationale:
A. Determining social skills is not directly related to task delegation.
B. Assessing ability to follow the client's teaching plan is beyond the scope of AP duties.
C. Providing a clear description of the task ensures that the AP understands what is expected, which is essential for effective delegation.
D. Evaluating ability to work with peers is important but not the primary focus for task delegation.