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 C

Explanation

A. Remind the client that they have been refusing the medication for 5 days: Pointing out the duration of refusal may come across as confrontational and does not respect the client's right to refuse treatment. It can also damage the therapeutic relationship without addressing the underlying concerns about the medication.

B. Inform the client that their provider will contact them to discuss their refusal of the medication: While involving the provider may eventually be necessary, the immediate nursing action should be to document the refusal accurately. The nurse can then inform the provider if needed based on facility policy.

C. Document the client's refusal in the medication administration record: Clients have the legal right to refuse medication, and it is the nurse’s responsibility to document the refusal clearly and objectively. Accurate documentation ensures legal protection for the client and the healthcare team and maintains the integrity of the medical record.

D. Notify the pharmacy about the client's refusal of the medication: Notifying the pharmacy about a single medication refusal is unnecessary unless there are repeated refusals requiring a change in the medication order. The pharmacy’s role is not to manage client compliance but to dispense prescribed medications.

A. Triiodothyronine B. Arterial blood gases C. Serum potassium D. Prothrombin time

Correct Answer is D

Explanation

Rationale:

A. Triiodothyronine: Triiodothyronine (T3) measures thyroid function and is not related to anticoagulation therapy. It is important for evaluating thyroid disorders but has no role in monitoring the effects of warfarin.

B. Arterial blood gases: Arterial blood gases (ABGs) assess oxygenation, ventilation, and acid-base balance, not anticoagulation status. ABGs are not used to monitor warfarin therapy.

C. Serum potassium: Serum potassium levels are crucial for cardiac and muscle function but are not affected directly by warfarin use. Potassium monitoring is more critical with diuretics or certain cardiac medications, not anticoagulants like warfarin.

D. Prothrombin time: Prothrombin time (PT) measures how long it takes blood to clot and is directly affected by warfarin therapy. Monitoring PT (and the related INR) ensures that the warfarin dose maintains therapeutic anticoagulation without causing excessive bleeding.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

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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