Practice Quiz

NCLEX-RN

Category - Care Management

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The nursing assistant reports to Nina the New Nurse, “I found Mr. Smythe on the floor of his room. He told me he tripped on the call-bell cord on the way to the bathroom. I helped him back to bed. He says he didn’t hurt anything; he’s a little shaken up.” After assessing Mr. Smythe for injuries, and assuring his safety, which of the following should be Nina the New Nurse’s next action or actions?
  1. Document the event, the follow-up findings, and the nursing actions in the medical record.
  2. Complete an incident report, but do not mention the incident in the medical record.
  3. Complete an incident report.
  4. Ask the nursing assistant to complete an incident report.
Explanation
Answer: A and D - The event is documented in the medical record by Nina the New Nurse; Nina the New Nurse should ask the nursing assistant to complete an incident report, as it was the nursing assistant who witnessed the event. The completion of an incident report is not noted in the medical record.
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