UWorld NCLEX-RN QBank Latest 2023 Graded A

UWorld NCLEX-RN QBank Latest 2023 Graded A The nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an incorrect entry in the client's medical record at what time? 1 Found client lying on floor next to bed. Client states, "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table." Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits (see assessment flow sheet). Client instructed to use call bell for assistance. Will continue to monitor.__________RN 2 Health care provider (HCP) notified of fall. Prescribed CT of head STAT.___________RN 3 No change in neurologic status. Client to CT via gurney. Report filed per policy.__________RN 4 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor.__________RN 3 Explanation: All incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported. The person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form. Alternately, a paper form may be completed and filed. The purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim. The nurse should not document that an incident report was filed, or refer to the incident report in the medical record.