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 A
Explanation
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg." This statement demonstrates correct technique for ascending stairs with crutches. When going up stairs, the client should advance the crutches onto the step first, followed by the unaffected leg.
Choice B Reason:
"I should keep my elbows straight when I am walking with my crutches." The client should maintain a slight bend in the elbows while walking with crutches to provide stability and support.
Choice C Reason:
"I will support my weight on the hand grips of the crutches." The client should not support their weight on the hand grips alone; weight should be distributed through the hands and arms to avoid putting excessive pressure on the axillae.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off." It is generally not advisable to walk with crutches without shoes, as wearing shoes provides better support and stability. The client should wear supportive, non-skid footwear while using crutches.
Correct Answer is B
Explanation
Choice A Reason:
Inflating the catheter's balloon is inappropriate. Inflating the balloon at this point is not recommended. The balloon should only be inflated once the catheter is in the bladder and urine starts to flow.
Choice B Reason:
Twisting the catheter gently is appropriate. Twisting the catheter gently may help navigate any obstruction or resistance within the urethra. However, it is crucial to be cautious and not force the catheter. If resistance persists or if the catheter cannot be advanced further, the nurse should reassess the situation and consider alternative actions, such as selecting a smaller catheter or seeking assistance from a more experienced healthcare provider.
Choice C Reason:
Applying lidocaine gel to the urethra is inappropriate. Applying lidocaine gel may be appropriate for lubrication and to minimize discomfort during catheter insertion, but it will not address the issue of resistance or lack of urine flow.
Choice D Reason:
Lowering the penis to a 45° angle is inappropriate. Adjusting the angle of the penis is not likely to resolve the issue of resistance. Twisting the catheter gently or reassessing the situation would be more appropriate.
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