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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.
- The other options are not appropriate at this stage:
Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.
Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.
Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.
Correct Answer is B
Explanation
This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.
Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.
Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.
The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.
Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.
The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.
Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.
The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.
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