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 reports being dissatisfied with the temperature of the meals provided.
A client receives burns from a heating pad.
A client becomes disoriented and falls out of bed.
A client is unable to afford the physical therapy that the provider recommends.
A client's visitor's getting dizzy and fainting in the client's room
Correct Answer : B,C,E
Choice A reason: A client's dissatisfaction with the temperature of the meals is not an incident that requires a report. The nurse should inform the dietary staff and try to accommodate the client's preferences.
Choice B reason: A client's burns from a heating pad is an incident that requires a report. The nurse should document the cause, extent, and treatment of the burns, as well as the client's response and any actions taken to prevent recurrence.
Choice C reason: A client's disorientation and fall out of bed is an incident that requires a report. The nurse should document the circumstances, injuries, and interventions related to the fall, as well as the client's response and any changes in the plan of care.
Choice D reason: A client's inability to afford the physical therapy is not an incident that requires a report. The nurse should refer the client to a social worker or a financial counselor who can assist with finding resources and options.
Choice E reason: A client's visitor's dizziness and fainting in the client's room is an incident that requires a report. The nurse should document the event, the visitor's condition, and any actions taken to assist the visitor.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Witnessing the client’s signature on a consent form is not necessary for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to witness the signature for invasive or high-risk procedures that require written consent.
Choice B reason: Obtaining verbal consent from the client is the appropriate action for the nurse to take before inserting an indwelling urinary catheter. The nurse should explain the purpose, benefits, risks, and alternatives of the procedure and ensure that the client understands and agrees to it.
Choice C reason: Having another nurse co-sign the client’s consent is not required for an indwelling urinary catheter insertion, which is a routine and noninvasive procedure. The nurse only needs to have another nurse co-sign the consent for procedures that involve blood transfusions, organ donations, or research participation.
Choice D reason: Checking the medical record for the client’s signature on a previous consent form is not sufficient for verifying the client’s express consent for an indwelling urinary catheter insertion. The nurse should obtain a new consent for each procedure, as the client has the right to change their mind or refuse the treatment at any time.
Correct Answer is A
Explanation
Choice A reason: Tightening the abdominal muscles is a good strategy to prevent back injury when lifting an object. The abdominal muscles support the spine and help maintain a neutral posture. Tightening them can reduce the stress on the back and prevent muscle strain or disc herniation.
Choice B reason: Bending at the waist is a bad strategy to prevent back injury when lifting an object. Bending at the waist can cause the spine to curve and lose its alignment. This can increase the pressure on the intervertebral discs and the spinal nerves, and lead to pain, inflammation, or nerve damage.
Choice C reason: Keeping legs straight is a bad strategy to prevent back injury when lifting an object. Keeping legs straight can limit the range of motion and the leverage of the lower body. This can force the back to do most of the work and increase the risk of injury. The nurse should bend the knees and hips and use the legs to lift the object.
Choice D reason: Holding the object away from the body is a bad strategy to prevent back injury when lifting an object. Holding the object away from the body can create a lever effect and increase the load on the back. This can cause the back muscles to overwork and fatigue, and lead to injury. The nurse should hold the object close to the body and keep it at the center of gravity.
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