A nurse is assisting in the care of a group of clients. For which of the following client events should the nurse complete an incident report?
A client has difficulty voiding following the removal of an indwelling catheter
A client reports nausea following the administration of morphine.
A client who has type 2 diabetes mellitus did not eat their breakfast
A client's arm is edematous at the peripheral IV site.
The Correct Answer is D
A. A client has difficulty voiding following the removal of an indwelling catheter: Difficulty voiding can be a common, expected postoperative or post-catheterization occurrence. It requires nursing interventions but does not warrant an incident report unless it results in harm or an adverse outcome.
B. A client reports nausea following the administration of morphine: Nausea is a known and common side effect of opioid medications like morphine. Monitoring and providing antiemetics are appropriate, but this event is anticipated and does not require an incident report.
C. A client who has type 2 diabetes mellitus did not eat their breakfast: Missing a meal may affect blood glucose control but is not considered a reportable incident. Nursing actions would include monitoring glucose and providing alternatives, rather than filing an incident report.
D. A client's arm is edematous at the peripheral IV site: Edema at an IV site may indicate infiltration, phlebitis, or extravasation, which are complications of intravenous therapy. Because it is a preventable or unexpected adverse event, it must be documented in an incident report to inform quality improvement and patient safety measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will notify my doctor if the stoma starts to look purple.": A stoma that appears purple can indicate compromised blood flow or ischemia, which is a medical emergency. Recognizing this sign and notifying the healthcare provider demonstrates understanding of proper stoma care and potential complications.
B. "I will irrigate the colostomy every day.": Ascending colostomies typically produce liquid to semi-liquid stool and are not routinely irrigated. Daily irrigation is usually reserved for descending or sigmoid colostomies to regulate bowel movements.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is usually liquid or semi-liquid because the stool has not yet passed through the majority of the colon where water absorption occurs. Expecting formed stool indicates a misunderstanding of colostomy output.
D. "I will empty the pouch every 2 to 3 hours.": Ascending colostomy output is frequent and liquid, but pouches are generally emptied when they are one-third to one-half full, not on a strict schedule. Overly frequent emptying is unnecessary and may increase the risk of skin irritation.
Correct Answer is D
Explanation
A. Waste containers are lined with single bags: Using single-lined waste containers is standard practice and does not pose a significant infection risk. Properly contained waste helps maintain cleanliness and reduce exposure to pathogens.
B. Dampened cloths are used for dusting the area: Using dampened cloths prevents dust from becoming airborne and spreading microorganisms. This method reduces the risk of infection and is appropriate for immunocompromised clients.
C. Uncapped sharps are put in a puncture-resistant container: Sharps should always be capped or handled carefully, but placing them directly in a puncture-resistant container is safe and prevents needlestick injuries.
D. Soiled linens are placed on the floor: Placing soiled linens on the floor exposes them to environmental pathogens and increases the risk of cross-contamination. For immunocompromised clients, proper handling and containment of soiled linens are critical to prevent infection.
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