A nurse is caring for a group of clients.
For which of the following situations should the nurse complete an incident
report? (Select all that apply.).

A client is unable to afford the physical therapy that the provider recommends.

A client reports being dissatisfied with the temperature of the meals provided.

A client’s visitor becomes dizzy and faints in the client’s room.

A client receives burns from a heating pad.

A client becomes disoriented and falls out of bed.

Answer and Explanation

Correct Answer : C,D,E

The correct answer is choice C, D, and E.

Choice A rationale: A client being unable to afford physical therapy is a financial issue, not an incident that affects patient safety or care quality. This situation should be addressed through social services or financial counseling, not an incident report.

Choice B rationale: A client being dissatisfied with meal temperature is a service quality issue, not a safety incident. This should be reported to the dietary department or patient services for resolution, not through an incident report.

Choice C rationale: A client’s visitor becoming dizzy and fainting in the client’s room is an incident that affects the safety of the visitor. An incident report should be completed to document the event, the visitor’s condition, and any actions taken to provide care or prevent future occurrences.

Choice D rationale: A client receiving burns from a heating pad is a safety incident that directly affects the client’s well-being. An incident report should be completed to document the injury, the circumstances leading to the burn, and any immediate care provided.

Choice E rationale: A client becoming disoriented and falling out of bed is a significant safety incident. An incident report should be completed to document the fall, the client’s condition, and any interventions implemented to prevent future falls.

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Correct Answer is D

Explanation

The correct answer is choice D. This type of device is useful for a client who cannot assist.

A mechanical lift is used to transfer residents who cannot support their own weight.

It does not require the client to use upper body strength, as choice A suggests.

The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.

The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.

Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.

A. Lowering the side rail on the side of the bed where they will stand to perform mouth care. B. Using an oral care sponge swab moistened with cool water to clean the client’s mouth. C. Wearing clean gloves to perform mouth care for the client. D. Using two gloved fingers to open the client’s mouth for cleaning.

Correct Answer is D

Explanation

The correct answer is D. Using two gloved fingers to open the client’s mouth for cleaning.

Choice A rationale:

Lowering the side rail on the side of the bed where the AP will stand is necessary for safe access to the client. However, the AP should ensure the opposite side rail is up to prevent the client from falling.

Choice B rationale:

Using an oral care sponge swab moistened with cool water is an appropriate method for cleaning the mouth of an unconscious client. It helps maintain oral hygiene and comfort.

Choice C rationale:

Wearing clean gloves is essential for infection control and is a standard practice when performing mouth care to protect both the client and the caregiver.

Choice D rationale:

Using two gloved fingers to open the client’s mouth is not recommended as it can cause injury to the caregiver if the client bites down reflexively. Instead, a padded tongue blade should be used to gently open the mouth.

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A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

Correct Answer is D

Explanation

A nurse observes assistive personnel (AP) perform mouth care for a client who is unconscious. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

A nurse in a provider’s office performs a fecal occult blood test with a positive result on a client. Which of the following clients may have a false positive result?

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is collecting data from a client who is immobile and has a potential deepvein thrombosis. Which of the following findings should the nurse report to the provider?

A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?

A nurse is wearing sterile gloves in preparation for assisting with a client’s sterile procedure. While waiting for the procedure to begin, how should the nurse position her hands?

A nurse is reinforcing teaching with a newly hired nurse about cultural sensitivity during death and dying. Which of the following information should the nurse include?

A nurse is assisting with scoliosis screenings for students at a public school. Which of the following findings should the nurse recognize as an indication of scoliosis?

A nurse is caring for a group of clients.
For which of the following situations should the nurse complete an incident
report? (Select all that apply.).