A charge nurse is discussing incident reports with a newly licensed nurse. Which of the following situations should the nurse identify as requiring an incident report?
A client refuses to attend physical therapy.
A visitor pinches his finger in the client's bed frame.
A client throws a box of tissues at a nurse.
A nurse administers a medication 30 min after the scheduled time.
The Correct Answer is B
Rationale:
A. A client refusing therapy is not an unusual occurrence and does not require an incident report—this should be documented in the nursing notes instead.
B. An injury to a visitor, staff, or client is considered an unusual event and requires an incident report for risk management and safety follow-up.
C. A client throwing tissues may be disruptive, but since no injury or safety issue occurred, an incident report is not required. Documentation of behavior is sufficient.
D. Administering medication 30 minutes late is generally within the accepted time frame for most scheduled medications and does not require an incident report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. The SBAR communication tool is used for structured communication among health care providers, not for measuring outcomes.
B. Flowcharts are used to map processes and identify where problems may occur, but they do not measure outcomes.
C. Clinical indicators are measurable items that reflect the quality of care provided (e.g., infection rates, fall rates, readmission rates). They are the appropriate tool for evaluating outcomes in quality improvement.
D. Cause-and-effect diagrams (Ishikawa or fishbone diagrams) are used to identify potential causes of a problem, not to measure outcomes.
Correct Answer is C
Explanation
Rationale:
A. It is not appropriate for the client to independently mark the operative site; this could lead to errors. Site marking must be done by the surgical team per protocol.
B. Contacting the surgery department does not directly resolve the client’s confusion or ensure proper informed consent.
C. The surgeon is responsible for confirming and clarifying the surgical site with the client. The nurse should advocate for the client’s safety by notifying the surgeon of the discrepancy.
D. Proceeding with surgery despite the client’s expressed concern would be unsafe and violates the principles of informed consent and patient safety.
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