A nurse is assisting in the care of a group of clients. Which of the following occurrences should the nurse identify as requiring an incident report?

A client who developed a pressure ulcer on the sacrum

A client who refused to take a prescribed stool softener

A client who reported feeling dizzy while ambulating

A client who received medication 1 hr after it was due

Answer and Explanation

The Correct Answer is A

A. A client who developed a pressure ulcer on the sacrum: The development of a pressure ulcer during hospitalization is considered a preventable adverse event and requires an incident report. It reflects a potential lapse in standard care practices related to skin integrity and client repositioning.

B. A client who refused to take a prescribed stool softener: Clients have the right to refuse medications. This occurrence should be documented in the medical record, but it does not require an incident report since it is an exercise of client autonomy.

C. A client who reported feeling dizzy while ambulating: Feeling dizzy during ambulation should be documented and addressed with safety measures, but if no fall or injury occurred, it typically does not necessitate a formal incident report.

D. A client who received medication 1 hr after it was due: A slight delay in medication administration may need to be documented depending on the medication's importance, but a 1-hour delay, unless involving critical medication like insulin or anticoagulants, usually does not require a formal incident report.

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Correct Answer is ["A","B","C"]

Explanation

A. Show the client pictures that illustrate the surgery: Visual aids can help bridge language barriers by providing a clear understanding of complex procedures. Pictures can reinforce verbal explanations and improve the client's ability to comprehend the surgical process, especially when language proficiency is limited.

B. Provide the client with written information in the client's primary language: Providing written materials in the client's native language ensures that the client has access to accurate, understandable information. This supports informed consent and allows the client to review the details at their own pace, enhancing comprehension.

C. Provide the client with a professional interpreter to explain the surgery: Using a professional medical interpreter is crucial for accurately conveying medical information. It ensures the client fully understands the procedure, risks, and benefits, which is necessary for informed consent and legal protection of client rights.

D. Ask a member of the client's family to discuss the surgery with the client: Family members should not be used as interpreters because they may lack medical knowledge and can introduce bias or inaccuracies. Relying on family could compromise the client's understanding and confidentiality.

E. Ask the client if they understand the risks of the surgery: Simply asking if the client understands without first ensuring effective communication through appropriate language services does not guarantee true understanding. The nurse must first use proper communication tools, like an interpreter or translated materials.

A. Disposes of contaminated sheets in a linen bag B. Wears clean gloves when performing oral hygiene C. Empties the sharps container when it is full D. Wears an N95 mask when bathing a client who has Clostridium difficile

Correct Answer is B

Explanation

A. Disposes of contaminated sheets in a linen bag: Contaminated linens should be placed in a designated leak-proof bag, often specifically marked for contaminated items. Simply disposing of them in a regular linen bag without proper precautions could lead to the spread of infection.

B. Wears clean gloves when performing oral hygiene: Wearing clean gloves during oral care is an effective and appropriate use of supplies to maintain standard precautions and protect both the client and the caregiver from potential contamination.

C. Empties the sharps container when it is full: The sharps container should be emptied when it is three-quarters full, not completely full. Waiting until it is full increases the risk of needlestick injuries and improper disposal practices.

D. Wears an N95 mask when bathing a client who has Clostridium difficile: For Clostridium difficile, the appropriate personal protective equipment includes gloves and a gown, not an N95 mask. C. difficile is transmitted via contact with spores, not through airborne particles.

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A nurse is assisting in the care of a group of clients. Which of the following occurrences should the nurse identify as requiring an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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