1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and
finds the client lying on the floor. The nurse performs an assessment, assists the client back to
bed, notifies the h
...
1. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and
finds the client lying on the floor. The nurse performs an assessment, assists the client back to
bed, notifies the health care provider of the incident, and completes an incident report. Which
statement should the nurse document on the incident report?
a. The client fell out of bed
b. The client climbed over the side rails
c. The client was found lying on the floor
d. The client became restless and tried to get out of bed. - ✔✔1. C- The incident report should
contain the client's name, age, and diagnosis. The report should contain a factual description of
the incident, any injuries experienced by those involved, and the outcome of the situation. The
correct option is the only one that describes the facts as observed by the nurse. Options 1, 2, and
4 are interpretations of the situation and are not factual information as observed by the nurse.
2. A client is brought to the emergency department by emergency medical services (EMS) after
being hit by a car. The name of the client is unknown, and the client has sustained a severe head
injury and multiple fractures and is unconscious. An emergency craniotomy is required.
Regarding informed consent for the surgical procedure, which is the best action?
a. Obtain a court order for the surgical procedure
b. Ask the EMS team to sign the informed consent
c. Transport the victim to the operating room for surgery
d. Call the police to identify the client and locate the family. - ✔✔2. C- In general, there are two
situations in which informed consent of an adult client is not needed. One is when an emergency
is present and delaying treatment for the purpose of obtaining informed consent would result in
injury or death to the client. The second is when the client waives the right to give informed
consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although
option 4 may be pursued, it is not the best action
3. The nurse has just assisted a client back to bed after a fall. The nurse and health care provider
have assessed the client and have determined that the client is not injured. After completing the
incident report, the nurse should implement which action net?
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