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 B
Explanation
A. Protamine sulfate: Protamine sulfate is used to reverse the effects of heparin, not warfarin. Administering it in warfarin toxicity would not effectively counteract the anticoagulant effect and could delay appropriate treatment.
B. Vitamin K: Vitamin K is the antidote for warfarin toxicity. It promotes synthesis of clotting factors II, VII, IX, and X, which are inhibited by warfarin, helping to restore normal coagulation and reduce the risk of bleeding.
C. Calcium gluconate: Calcium gluconate is primarily used to treat hypocalcemia or cardiac effects of hyperkalemia. It does not reverse warfarin-induced anticoagulation and would not address the underlying risk of bleeding.
D. Acetylcysteine: Acetylcysteine is an antidote for acetaminophen toxicity and works by replenishing glutathione. It has no effect on warfarin metabolism or clotting factor synthesis, making it inappropriate for this scenario.
Correct Answer is C
Explanation
A. Offer the child nutritious snacks between meals: Providing healthy snacks can improve caloric intake in toddlers. However, implementing interventions without first understanding the child’s usual eating patterns may overlook underlying causes of poor intake.
B. Instruct the family to praise the child when they eat: Positive reinforcement can encourage eating behaviors in young children. This strategy is more effective after the nurse has assessed contributing factors and tailored education to the family’s needs.
C. Obtain the child's dietary history: Collecting a detailed dietary history is the priority initial action. It allows the nurse to assess patterns, preferences, cultural factors, and potential deficiencies before planning appropriate interventions.
D. Encourage the family to be with the child during mealtimes: Family presence during meals can support healthy eating habits in toddlers. However, this intervention should follow assessment to ensure it addresses the specific factors contributing to poor intake.
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