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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"Your doctor has an excellent reputation for being honest with clients." This response is incorrect. While intending to provide reassurance, this statement may come across as dismissive of the client's feelings and might not address their immediate concern.
Choice B Reason:
"Why do you think the doctor is lying?" This response is incorrect. This response might come off as confrontational or defensive. It could potentially escalate the client's emotions and not effectively address their feelings of being misled.
Choice C Reason:
"You feel as if the doctor hasn't been honest with you?" This response acknowledges the client's emotions and concerns without making assumptions about the doctor's actions. It demonstrates empathy and allows the client to express their feelings and concerns further.
Choice D Reason:
"I am certain the doctor would not lie to you." This response might be perceived as dismissive or invalidating of the client's feelings and beliefs, as it asserts the nurse's certainty without fully understanding the client's perspective.
Correct Answer is B
Explanation
A. Check a client's peripheral IV site for redness or swelling.
This task involves assessing the client's IV site for signs of complications. While it requires observation and reporting, it may involve some interpretation and judgment. This task is better suited for a licensed nurse.
B. Measure the intake and output of a client who has received furosemide.
Measuring intake and output is a routine task that involves quantifying the fluids a client consumes and eliminates. This is a task that can be appropriately delegated to an assistive personnel (AP) under the supervision and direction of the nurse.
C. Reinforce teaching with a client about crutch-gait walking.
Teaching requires a level of education, explanation, and clarification that goes beyond routine tasks. This is typically a nursing responsibility and should not be delegated to an AP.
D. Assess the pain level of a client who has received acetaminophen.
Pain assessment involves subjective information, and determining the appropriate response may require clinical judgment. This task is better suited for a licensed nurse.
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