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: A weight-sensitive sensor mat is a device that alerts the staff when a client tries to get out of bed. It is not a safety hazard, but rather a safety measure to prevent falls.
Choice B reason: A buzzing sensation at the application site of a transcutaneous electrical nerve stimulation unit is normal and expected. It indicates that the unit is delivering electrical impulses to the nerves and muscles. It is not a safety hazard, but rather a therapeutic intervention for pain relief.
Choice C reason: A capillary refill of less than 2 seconds is normal and indicates adequate blood circulation. It is not a safety hazard, but rather a sign of good perfusion.
Choice D reason: Raising all four side rails of a client's bed is a safety hazard because it increases the risk of injury if the client tries to climb over them. It also restricts the client's mobility and may cause feelings of isolation and imprisonment. It is a violation of the client's rights and dignity.
Correct Answer is B
Explanation
Choice A reason: Fidelity is not the ethical principle that the nurse is implementing. Fidelity is the duty to keep one's promises and commitments to the client. The nurse is not demonstrating fidelity by giving pain medication, unless the nurse has promised to do so.
Choice B reason: Beneficence is the ethical principle that the nurse is implementing. Beneficence is the duty to do good and prevent harm to the client. The nurse is demonstrating beneficence by giving pain medication to relieve the client's suffering and promote comfort.
Choice C reason: Autonomy is not the ethical principle that the nurse is implementing. Autonomy is the right of the client to make their own decisions and choices about their health care. The nurse is not demonstrating autonomy by giving pain medication, unless the client has consented to it.
Choice D reason: Veracity is not the ethical principle that the nurse is implementing. Veracity is the duty to tell the truth and be honest with the client. The nurse is not demonstrating veracity by giving pain medication, unless the nurse has explained the purpose, benefits, and risks of the medication.
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