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 B
Explanation
Rationale:
A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.
B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.
C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.
D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. Check the position of a client in soft wrist restraints is appropriate for an AP as it involves routine monitoring and ensuring the client's safety.
B. Accompany a client who has depression to occupational therapy is a task that can be assigned to an AP, as it involves providing support and ensuring the client's safe arrival to therapy.
C. Set limits with a client who has mania is not appropriate for an AP, as this involves therapeutic communication and behavior management, which requires nursing judgment.
D. Sit with a client who has alcohol use disorder and whose last drink was five days ago can be assigned to an AP as it involves providing a supportive presence and monitoring, but the nurse should assess for withdrawal symptoms.
E. Assess a client who has hypomania for exhaustion is a nursing responsibility that involves evaluation and judgment, making it inappropriate to delegate to an AP.