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

Answer and Explanation

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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Correct Answer is A,B,C,E,D

Explanation

Choice 1 reason: This is the first step because cleaning the urinary meatus reduces the risk of infection and contamination.

Choice 2 reason: This is the second step because separating the labia exposes the urethral meatus and facilitates the insertion of the catheter.

Choice 3 reason: This is the third step because inserting the catheter into the urethral meatus allows the urine to drain into the collection bag.

Choice 4 reason: This is the fourth step because inflating the catheter balloon secures the catheter in place and prevents it from slipping out.

Choice 5 reason: This is the fifth step because securing the catheter to the client's thigh prevents tension and traction on the catheter and the bladder.

A. "We will receive emotional support during our mother’s illness." B. "We will provide resuscitation to our mother if necessary." C. "We won’t discuss the illness in the presence of our mother." D. "We won’t allow her spiritual advisor to visit during this time."

Correct Answer is A

Explanation

Choice A reason: Receiving emotional support during the mother’s illness is a sign of understanding the teaching. Palliative care is a holistic approach that aims to improve the quality of life of clients and their families who are facing life-threatening illnesses. It provides physical, psychological, social, and spiritual support to address their needs and preferences.

Choice B reason: Providing resuscitation to the mother if necessary is a sign of misunderstanding the teaching. Palliative care focuses on relieving symptoms and suffering, not curing the illness or prolonging life. It respects the client’s wishes and goals of care, which may include a do-not-resuscitate (DNR) order or an advance directive.

Choice C reason: Not discussing the illness in the presence of the mother is a sign of misunderstanding the teaching. Palliative care encourages open and honest communication between the client and the family, as well as the health care team. It helps the client and the family cope with the illness, express their emotions and concerns, and make informed decisions.

Choice D reason: Not allowing the mother’s spiritual advisor to visit during this time is a sign of misunderstanding the teaching. Palliative care recognizes the importance of spirituality and religion for some clients and their families. It supports the client’s right to practice their faith and receive spiritual guidance and comfort from their chosen source.

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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 inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,E,D

Explanation

A nurse is reinforcing teaching with the adult children of a client who is receiving palliative care. Which of the following statements by one of the adult children indicates an understanding of the teaching?

Correct Answer is A

Explanation

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