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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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 A
Explanation
Choice A reason: This is correct because a mechanical lift is designed to safely transfer a client who has limited or no mobility and cannot assist with the transfer.
Choice B reason: This is incorrect because the sides of the sling are not for the client to hold onto, but for the nurse to attach the hooks of the lift.
Choice C reason: This is incorrect because the lower end of the sling goes under the client's thighs, not below the client's calves
Choice D reason: This is incorrect because the device does not require the client to use upper body strength, but rather supports the client's weight and movement.
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