NCLEX Practice Questions ( Answer # 15)

A nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse implements which action next?

1. Reassess the client.

2. Conduct a staff meeting to describe the fall.

3. Document in the nurse’s notes that an incident report was completed.

4. Contact the nursing supervisor to update information regarding the fall.

Rationale

Answer and Rationale:  Option 1 is Correct answer. Rationale: After a client’s fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client’s fall should be treated as private information and shared on a “need to know” basis. Communication regarding the event should involve only the individuals participating in the client’s care. An incident report is a problem-solving document; however, its completion is not documented in the nurse’s notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is desired. Test-Taking Strategy: Focus on the data in the question and the strategic word next. Using the steps of the nursing process will direct you to option 1. Remember that assessment is the first step. Review guidelines related to incident reports and care to the client after sustaining a fall if you had difficulty with this question.

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