Question of the Day: The Nursing Process

Q. During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which of the following activities should the nurse perform after finishing the incident report?

 A. Attach a copy to the client's records.
 B. Highlight the mistake in the client's records.
 C. Include the time and date of the incident.
 D. Mention the name of the nursing assistant in the client records.

Correct Answer: C

Explanation: The nurse should include the date and time of the incident in the incident report, the events leading up to it, the client's response, and a full nursing assessment. To prevent legal issues, the nurse should not attach the copy of the incident report to the client's records. Also to prevent litigation, the mistake should not be highlighted in the client's records. As the client report is a legal document, it should not contain the name of the nursing assistant.