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 A
Explanation
The correct answer is choice A. Interlock her fingers and hold her hands away from her body above her waist.
This is because this position minimizes the risk of contaminating the sterile gloves by touching any non-sterile surfaces or objects.
The nurse should also keep her hands above her waistline to prevent contamination
Choice B is wrong because clasping the hands together behind the body at the waist could contaminate the gloves by touching the non-sterile gown or the skin
Choice C is wrong because placing one hand over the other against the part of the gown covering the upper body could contaminate the gloves by touching the non-sterile gown or the skin
Choice D is wrong because keeping the arms at the sides of the body with the hands in a relaxed position could contaminate the gloves by touching any nonsterile surfaces or objects
Sterile gloves are a type of disposable rubber gloves that are put through specific procedures to eliminate germs and microorganisms.
They are used to prevent and minimize infection during surgeries or invasive procedures
Correct Answer is D
Explanation
The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.
It is used for vaginal and colonic examinations and natural childbirth.
Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.
The left arm should be behind the back.
Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.
The lower leg should be straightened and the upper leg should be bent.
Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.
The bed should be flat or slightly tilted.
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