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 D

Explanation

A. "Advance directives are the same as a consent form for health care treatment": Advance directives are different from a consent form. A consent form is specific to the current treatment or procedure, while advance directives outline future healthcare wishes in the event the client becomes unable to make decisions.

B. "Advance directives are for clients who have life-threatening conditions.": While advance directives are especially important for clients with serious illnesses, they are appropriate for all adults, regardless of current health status, to ensure their wishes are known and respected if they become incapacitated.

C. "Advance directives must be approved by your lawyer.": Advance directives do not require a lawyer's approval to be valid. They usually need to be signed by the client and witnessed or notarized, depending on state laws, but legal counsel is not mandatory for completing one.

D. "Advance directives protect your right to make your own health care decisions.": Advance directives ensure that a client’s wishes regarding healthcare are known and respected even if they cannot voice them later. They preserve the client’s autonomy and legal rights concerning treatment preferences.

A. Request the family members leave the client's room B. Place dentures in the client's mouth. C. Remove the client's personal hair pieces. D. Lower the head of the client's bed.

Correct Answer is B

Explanation

A. Request the family members leave the client's room: Family members may choose to stay if they wish, and they should be allowed to participate or be present during postmortem care if it aligns with their emotional needs or cultural practices. Forcing them to leave is not appropriate unless required for specific procedures.

B. Place dentures in the client's mouth: Placing dentures helps maintain the natural shape and appearance of the face, offering a more familiar and comforting appearance for the family during viewing. This is an important step in preparing the body respectfully.

C. Remove the client's personal hair pieces: Hairpieces should be left in place unless the family or facility policy requests otherwise. Removing them without need can alter the client’s appearance and potentially distress the family.

D. Lower the head of the client's bed: The head of the bed should be elevated slightly, not lowered, to prevent blood from pooling in the head and face, which could cause discoloration and swelling before the family views the body.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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