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. The nurse should respect the client’s autonomy and offer assistance if needed.

The nurse should also assess the client’s pain level and provide adequate pain relief before helping the client get out of bed.

Choice A is wrong because it implies that the client is in pain and needs medication, which may not be true.

The nurse should ask the client about their pain level and offer medication if appropriate.

Choice B is wrong because it dismisses the client’s feelings and does not address the underlying issue of why the client does not want to be touched.

Choice C is wrong because it may make the client feel defensive or interrogated.

The nurse should use open-ended questions and active listening to explore the client’s concerns and fears.

According to web sources, postoperative care involves monitoring and managing the client’s vital signs, pain, wound healing, fluid and electrolyte balance, bowel and bladder function, mobility, and psychological status.

The nurse should also educate the client about self-care, wound care, activity restrictions, medication use, signs of complications, and follow-up appointments.

The nurse should also provide emotional support and reassurance to the client and their family.

A. A. A client who has a venous stasis ulcer. B. A client who has peripheral hematomas. C. A client who underwent a barium swallow study. D. A client who takes an iron supplement.

Correct Answer is C

Explanation

Correct answer: C

A. A client who has a venous stasis ulcer: This is less likely to cause a false positive result. While ulcers can bleed, the fecal occult blood test is designed to detect small amounts of blood in the stool, not necessarily blood from other sources like venous stasis ulcers.

B. A client who has peripheral hematomas: Peripheral hematomas are typically not related to the fecal occult blood test. They generally wouldn’t affect the results unless there was significant bleeding or if the hematomas were a result of an underlying bleeding disorder.

C. A client who underwent a barium swallow study: This is the most likely to cause a false positive result. Barium used in the study can sometimes appear as a false positive on the test due to its interference with the chemical reactions used to detect blood.

D. A client who takes an iron supplement: Iron supplements can actually cause a false negative result rather than a false positive because they may darken the stool and mask the presence of blood.

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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 assisting a client who is 4 hr postoperative to get out of bed. The client states, “Do not touch me! I can get up by myself.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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?

Correct Answer is C

Explanation

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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?

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A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to take?

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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.).