A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

A family member is napping in the client's room.

A client refuses to eat at mealtime

A client's bed alarm is malfunctioning

An assistive personnel is late for the upcoming shift

Answer and Explanation

The Correct Answer is C

A. A family member is napping in the client's room.

This situation, while not ideal, doesn't involve harm or potential harm to a client, staff, or visitor. It may be addressed through communication and policy reminders but may not require an incident report.

B. A client refuses to eat at mealtime.

Client refusal to eat, while concerning, is not an unexpected or unusual event. It is a common aspect of care, and incident reports are not typically used for such situations.

C. A client's bed alarm is malfunctioning.

This situation involves a malfunction in equipment designed to ensure client safety. It has the potential to compromise the safety of the client and may require an incident report to document the issue and address it appropriately.

D. An assistive personnel is late for the upcoming shift.

Lateness may be an issue that needs addressing, but it's not typically considered an incident requiring a formal incident report. This situation may be addressed through workplace policies and communication.

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Correct Answer is A

Explanation

Choice A Reason:

Placing the drainage system below the client's chest level is appropriate. This positioning allows for proper drainage and prevents the backflow of fluid or air into the chest. Maintaining the drainage system below the chest level helps ensure effective evacuation of air or fluid from the pleural space.

Choice B Reason:

Looping excess tubing next to the client's side is inappropriate. Looping excess tubing can create dependent loops, potentially causing fluid to accumulate in these areas and compromising the drainage system's effectiveness.

Choice C Reason:

Clamping the tubing when ambulating the client is inappropriate. Chest tube drainage systems should not be routinely clamped during ambulation. Clamping can lead to increased pleural pressure, potentially causing tension pneumothorax or other complications.

Choice D Reason:

Milking the client's tubing every shift is inappropriate. Milking or stripping the tubing is not recommended, as it can create a pressure gradient that may damage the lung tissue or disrupt the chest tube's seal. Passive drainage is preferred to maintain the negative pressure in the system.

A. Open the innermost lower flap of the sterile kit while standing away from the sterile field. B. Open each side flap of the sterile kit individually while pulling to the side. C. Open the outside cover of the sterile kit and remove the dust cover. D. Grasp the outermost flap of the sterile kit while opening away from the body. E. Prepare a dry work surface above the waist level.

Correct Answer is E,C,D,B,A

Explanation

Choice E Reason:

Preparing a dry work surface above the waist level. It's crucial to start by selecting and preparing an appropriate area for setting up the sterile field. This surface needs to be clean, dry, and above the waist level to maintain sterility and prevent contamination.

Choice C Reason:

Opening the outside cover of the sterile kit and remove the dust cover. This step involves opening the sterile kit without touching the inside contents to maintain sterility. Removing the outer cover exposes the sterile packaging and prepares for further steps.

Choice D Reason:

Grasping the outermost flap of the sterile kit while opening away from the body. By carefully opening the outermost flap, the nurse ensures that the sterile contents remain protected. Opening away from the body helps prevent accidental contamination from clothing or movements.

Choice B Reason:

Opening each side flap of the sterile kit individually while pulling to the side. Sequentially opening the side flaps maintains the sterile field and allows access to the inner contents without compromising sterility.

Choice A Reason:

Opening the innermost lower flap of the sterile kit while standing away from the sterile field. This final step involves accessing the innermost contents of the sterile kit while maintaining a safe distance to avoid accidental contamination. It ensures the contents within the sterile field remain protected until needed for the dressing change.

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A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a closed chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Placethem in the order of performance. Use all the steps.)

Correct Answer is E,C,D,B,A

Explanation

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