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 C
Explanation
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
Correct Answer is A
Explanation
This is because the nurse should first assess the client’s baseline knowledge and readiness to learn before providing any teaching.
The nurse should also tailor the teaching to the client’s individual needs and preferences.
Choice B is wrong because showing the client a video demonstration of peak flow meter use may not be the most effective way of teaching if the client has different learning styles or needs.
The nurse should also involve the client in the learning process and not just rely on passive methods.
Choice C is wrong because observing the client using the peak flow meter is an evaluation step that should be done after teaching and reinforcing the correct technique.
The nurse should not assume that the client knows how to use the peak flow meter without assessing their knowledge first.
Choice D is wrong because emphasizing the importance of the daily use of the peak flow meter is a motivational strategy that should be done after assessing the client’s knowledge and providing teaching.
The nurse should also explain the rationale and benefits of using the peak flow meter, not just tell the client to do it.
A peak flow meter is a small device that measures how fast a person can forcefully blow air out of their lungs in one fast breath.
It is one indicator of airways changes that may occur in people with asthma or COPD.
To get a peak flow meter, speak to a doctor.
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