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. The client needs routine wound care performed: Routine wound care is a stable, predictable task that can be delegated to assistive personnel. It does not require the judgment or assessment skills of a registered nurse.
B. The client develops a postoperative fever: A postoperative fever may indicate infection or another complication that requires assessment, clinical judgment, and possible intervention by a registered nurse. This warrants transfer of care to the RN for evaluation and appropriate action.
C. The client is experiencing a therapeutic effect from their treatment: Observing a therapeutic response is expected and does not necessitate RN-only care. Monitoring for ongoing effectiveness can be performed by other trained personnel as appropriate.
D. The client needs strict measurement of intake and output: While accurate intake and output monitoring is important, it is a routine, measurable task that can be delegated to assistive personnel. It does not require RN assessment unless abnormalities are noted.
Correct Answer is B
Explanation
A. Dorsal recumbent: Lying flat on the back does not optimize airway protection or reduce strain on the surgical site after a thyroidectomy. This position may increase discomfort and risk of edema.
B. Semi Fowler's: Elevating the head of the bed to a semi-Fowler’s position helps reduce neck swelling, promotes airway patency, and decreases tension on the suture line. It also facilitates easier breathing and comfort during the postoperative period.
C. Left lateral: Side-lying positions are not indicated after a thyroidectomy unless the client has specific complications. They do not provide the same benefits for airway management and suture care as semi-Fowler’s.
D. Supine: Lying completely flat can increase neck edema and discomfort post-thyroidectomy. Maintaining a semi-Fowler’s position is preferred to support recovery and airway safety.
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