Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?
A. The client fell because the assistive personnel did not place nonskid slippers on the client."
B. The client does not appear to have any injuries resulting from the fall."
C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'."
The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
D. "An incident report has been completed and sent to risk management."
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
Similar Questions
A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?
A. Apply pressure to the lacrimal punctum after administering the drops.
The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.
B. Position the child side-lying on the bed before administering the drops.
C. Flush the eye with normal saline solution before administering the drops
D. Wipe from the outer to the inner canthus after administering the drops.
Full Explanation
The correct answer is A. The nurse should apply pressure to the lacrimal punctum, which is located at the inner corner of each eye, after administering eye drops to prevent systemic absorption of the medication and reduce side effects. The nurse should position the child supine or sitting with their head tilted back slightly before administering eye drops, as this allows for easier instillation and prevents spillage of medication. The nurse does not need to flush the eye with normal saline solution before administering eye drops, unless there is debris or discharge in the eye that needs to be removed. The nurse should wipe from the inner to the outer canthus after administering eye drops, as this prevents contamination of the eye and reduces the risk of infection.
A nurse is reinforcing teaching with a client who is about to undergo surgery. Which of the following statements about informed consent should the nurse include in the teaching?
A. "We require informed consent for all routine treatments."
B. "A family member must witness your signature on the informed consent form."
C. "We can accept verbal consent unless the surgical procedure is an emergency."
D. "You can sign the informed consent form after the provider explains the pros and cons of the procedure."
Informed consent is a process of providing information that enables the patient to make a decision to undergo a specific treatment. It requires time, patience and clarity of explanation. Consent should be obtained prior to surgery and ensure that the patient has sufficient time and information to make an informed decision. The provider should explain the indications, risks, benefits and alternatives of the procedure.
Full Explanation
The correct answer is D. Informed consent is a process of providing information that enables the patient to make a decision to undergo a specific treatment. It requires time, patience and clarity of explanation. Consent should be obtained prior to surgery and ensure that the patient has sufficient time and information to make an informed decision. The provider should explain the indications, risks, benefits and alternatives of the procedure.
A nurse is caring for a client who has an indwelling catheter with a urinary drainage system.Which of the following actions should the nurse take?
A. Collect a sterile specimen from the urinary drainage bag.
Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.
B. Secure the tubing with adhesive tape to the lower abdomen.
In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.
C. Instruct the client to hold the drainage bag at waist height when ambulating.
Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.
D. Coil the tubing on the bed above the collection bag.
Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.
Full Explanation
A. Urinary specimens collected from the bag may be contaminated and do not provide a reliable sample. A sterile specimen should be collected from the catheter port if needed.
B. In male patients secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension.
C. Guidelines recommend that the urinary drainage bag be kept below the level of the bladder, typically lower than the waist, to ensure proper urine flow and prevent reflux.
D. Coiling the tubing can impede proper drainage, leading to potential complications like urinary retention and infection.