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 D
Explanation
A. “I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.
B. “My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.
C. “My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.
D. “I really wish I had a girl instead.”: Expressing regret or disappointment regarding the baby’s sex may indicate difficulty bonding, gender preference stress, or emerging postpartum mood disturbances. This statement warrants further assessment for postpartum depression, anxiety, or adjustment issues to ensure maternal-infant wellbeing.
Correct Answer is A
Explanation
A. “Are you thinking of hurting yourself?”: This response directly and calmly assesses for suicidal ideation, which is essential when a client expresses feelings of worthlessness or passive death wishes. Asking clearly about self-harm allows the nurse to determine risk and initiate appropriate safety interventions.
B. “What would your family do without you?”: This response may increase guilt or emotional distress rather than encouraging open communication. It does not assess the client’s immediate safety or suicidal thoughts.
C. “When you get better you will not feel this way.”: This response minimizes the client’s current feelings and may make the client feel unheard or dismissed. It does not address potential suicidal risk or provide emotional support.
D. “Why would you think a thing like that?”: Asking “why” can sound judgmental and may discourage the client from sharing further. It does not assess for suicidal intent and may increase defensiveness or withdrawal.
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