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. “We can accept verbal consent unless the surgical procedure is an emergency”: Verbal consent is generally insufficient for surgical procedures except in true emergencies when the client is unable to consent. Surgical informed consent typically requires written documentation to meet legal and ethical standards.
B. “You can sign the informed consent form after the provider explains the pros and cons of the procedure”: Informed consent requires that the provider explain the nature of the procedure, risks, benefits, and alternatives before the client signs. The nurse’s role is to reinforce understanding and verify that the consent is given voluntarily.
C. “A family member must witness your signature on the informed consent form.”: A family member is not required to witness informed consent. A nurse or authorized healthcare staff may serve as a witness to the client’s signature, confirming that it was signed voluntarily.
D. “We require informed consent for all routine treatments.”: Routine treatments and nursing care generally fall under implied consent. Formal informed consent is required for invasive procedures, surgeries, and treatments with significant risk, not for all routine care.
Correct Answer is B,A,D,C
Explanation
A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.
B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.
C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.
D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.
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