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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is incorrect because the client should urinate before the specimen collection to avoid contaminating the stool with urine.
Choice B reason: This is incorrect because the specimen should be kept in a cool area to prevent bacterial growth and decomposition.
Choice C reason: This is incorrect because the client should place at least 2.5 cm (1 in) of formed stool or 15 to 30 mL of liquid stool into a culture tube.
Choice D reason: This is correct because the client should avoid placing toilet tissue in the bedpan after defecation to prevent interfering with the laboratory analysis of the stool.
Correct Answer is B
Explanation
Choice A reason: Isopropyl alcohol is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Isopropyl alcohol is effective against some bacteria, viruses, and fungi, but not against Clostridium difficile spores. These spores are resistant to alcohol and can survive on surfaces for a long time.
Choice B reason: Chlorine bleach is a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Chlorine bleach is effective against a wide range of microorganisms, including Clostridium difficile spores. It can kill the spores and prevent their spread. The nurse should use a diluted bleach solution (1:10) and follow the manufacturer's instructions for contact time and safety precautions.
Choice C reason: Chlorhexidine is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Chlorhexidine is an antiseptic that is used for skin cleansing and wound care. It is not effective against Clostridium difficile spores and can promote their growth.
Choice D reason: Triclosan is not a good solution to use for disinfecting the room of a client who has a Clostridium difficile infection. Triclosan is an antibacterial agent that is used in some soaps, toothpastes, and cosmetics. It is not effective against Clostridium difficile spores and can contribute to antibiotic resistance.
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