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 B

Explanation

The correct answer is choice B: Explain to the client that they cannot leave until the surgeon discharges them.

Choice B rationale: The nurse should explain the importance of following the surgeon's orders and the potential consequences of leaving before being officially discharged. This approach provides patient education and promotes collaboration between the client and the health care team. It also ensures the client understands that leaving without proper discharge could lead to complications or inadequate recovery.

Choice A rationale: Threatening the client with restraints is not an appropriate action, as it may cause undue stress and escalate the situation. Restraints should only be used as a last resort in cases where the client poses an immediate risk of harm to themselves or others.

Choice C rationale: While having the client sign an against medical advice (AMA) form might be appropriate if the client insists on leaving, the nurse should first attempt to educate the client on the importance of following the surgeon's orders and collaborate with the client to resolve any concerns or issues leading to their desire to leave.

Choice D rationale: Administering a sedative medication is not an appropriate action in this situation. Sedation should only be used when medically necessary and not as a means to control a client's behavior or decisions.

A. Goggles. B. Gown. C. Mask. D. Gloves.

Correct Answer is D

Explanation

The nurse should remove the gloves first because they are the most contaminated piece of personal protective equipment (PPE) and should be discarded as soon as possible.

The nurse should then remove the gown, which may also be soiled with blood or body fluids, by grasping it at the neck and peeling it off inside out.

The mask and goggles should be removed last, by touching only the straps or earpieces, and avoiding touching the front of the mask or the lenses of the goggles.

Choice A is wrong because goggles are not the most contaminated piece of PPE and should be removed after the gown.

Choice B is wrong because gown is not the most contaminated piece of PPE and should be removed after the gloves.

Choice C is wrong because mask is not the most contaminated piece of PPE and should be removed after the gown and goggles.

Normal ranges for wound irrigation pressure are between 4 and 15 psi (pounds per square inch).

Higher pressures may damage the wound tissue and increase the risk of infection.

Lower pressures may not be effective in removing debris and bacteria from the wound.

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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 caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement. The nurse enters the client’s room and finds them dressing and stating that they are going home. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is performing a wound irrigation for a client who has methicillin-resistant Staphylococcus aureus. When removing personal protective equipment, which of the following pieces should the nurse remove first?

Correct Answer is D

Explanation

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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.).