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:

Recording the urinary output at the end of each shift is appropriate action. Furosemide is a loop diuretic that increases urine production. Monitoring urinary output is important to assess the effectiveness of the medication and to ensure that the client is not at risk for dehydration or fluid overload. Recording urinary output at the end of each shift provides a comprehensive overview of the client's renal function and fluid balance.

Choice B Reason:

Checking the urine for ketones every 12 hr is inappropriate action. Checking urine for ketones is not a routine assessment for a client with an indwelling urinary catheter and a prescription for furosemide.

Choice C Reason:

Collecting a 24-hr urine specimen to send to the laboratory is inappropriate. Collecting a 24-hour urine specimen is a more extensive test and is not typically needed for routine monitoring of a client on furosemide.

Choice D Reason:

Measuring the specific gravity of the urine during each shift is incorrect. While monitoring specific gravity can provide information about the concentration of urine, it is not usually required for routine monitoring in this specific situation. Monitoring urinary output is a more practical and clinically relevant approach.

A. Consume probiotic sources. B. Use a laxative every day. C. Bake with white flour. D. Take a calcium supplement.

Correct Answer is A

Explanation

Choice A Reason:

Consuming probiotic sources is recommendable. Probiotics are beneficial bacteria that can promote gut health. Including probiotic sources in the diet, such as yogurt with live cultures or other fermented foods, can help maintain a healthy balance of gut bacteria and alleviate constipation.

Choice B Reason:

Using a laxative every day is not recommendable. Regular use of laxatives is generally not recommended for chronic constipation, as it can lead to dependence and may not address the underlying causes.

Choice C Reason:

Baking with white flour is not recommendable. Consuming refined white flour may not contribute significantly to relieving constipation. Whole grains, high-fiber foods, and adequate fluid intake are more beneficial.

Choice D Reason:

Taking a calcium supplement is not recommendable. While calcium is important for overall health, taking a calcium supplement is not typically recommended as the primary intervention for chronic constipation. Dietary and lifestyle measures, such as increasing fiber intake and staying hydrated, are more commonly recommended.

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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 caring for a client who has an indwelling urinary catheter and a prescription for furosemide. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has chronic constipation. Which of the following actions should the nurse recommend to the client?

Correct Answer is A

Explanation

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