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 B
Explanation
Choice A Reason:
Inflating the catheter's balloon is done after proper placement to secure the catheter in the bladder. It should not be done when there is resistance and no urine flow.
Choice B Reason:
Twisting the catheter gently is correct. Resistance during catheter insertion may indicate the catheter is encountering an obstruction or is misaligned. Gently twisting the catheter can help navigate around obstructions or correct misalignment without causing trauma to the urethra.
Choice C Reason:
Applying lidocaine gel to the urethra is typically used for lubrication and to numb the urethra during catheter insertion, but it may not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is not a standard action in response to resistance during catheter insertion. Twisting the catheter gently is a more appropriate initial step.
Correct Answer is A
Explanation
Choice A Reason:
A client can withdraw consent at any time is appropriate. This statement is accurate. Informed consent is a voluntary process, and a client has the right to withdraw their consent at any point before or during a medical procedure.
Choice B Reason:
A family member should witness the client's consent is not a standard practice. Typically, a witness is someone who is neutral and not directly involved in the procedure.
Choice C Reason:
A nurse is responsible for obtaining informed consent is not entirely accurate. While nurses may provide information and answer questions, obtaining informed consent is typically the responsibility of the healthcare provider performing the procedure.
Choice D Reason:
A minor who is pregnant is unable to give consent is not a universally true statement. The ability of a minor to give consent can vary based on legal and ethical considerations, and it may depend on local laws and regulations.
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