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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Using a narrower cuff to repeat the BP measurement is an incorrect action by the nurse, as it can result in a falsely high reading. The nurse should use a cuff that fits the client's arm size and circumference.

Choice B reason: Measuring the client's BP in the other arm is the correct action by the nurse, as it can help to confirm the accuracy of the reading and rule out any possible errors or variations. The nurse should compare the readings from both arms and report any significant differences to the provider.

Choice C reason: Deflating the cuff faster when repeating the BP measurement is an incorrect action by the nurse, as it can result in a falsely low reading. The nurse should deflate the cuff at a rate of 2 to 3 mm Hg per second.

Choice D reason: Requesting a prescription for an antihypertensive medication is an inappropriate action by the nurse, as it is premature and unnecessary. The nurse should first verify the BP reading and identify the possible causes of the elevation, such as pain, anxiety, or medication effects. The nurse should also implement nonpharmacological interventions, such as positioning, relaxation, and oxygen therapy, before administering any medication.

A. Stand on the client's stronger side when moving the client into the chair. B. Raise the bed to waist level before moving the client. C. Flex hips and knees when assisting the client to a standing position. D. Pivot on the foot farthest from the bed when assisting the client into the chair.

Correct Answer is C

Explanation

Choice A reason: Standing on the client's stronger side may cause the client to lean or fall toward the weaker side. The nurse should stand on the client's weaker side and support the client's trunk and affected arm.

Choice B reason: Raising the bed to waist level may make it harder for the client to move their legs over the edge of the bed. The nurse should lower the bed to the lowest position and raise the head of the bed to a sitting position.

Choice C reason: Flexing hips and knees helps the client use their stronger leg muscles and maintain balance when standing up. The nurse should also place one arm under the client's axilla and the other arm around the client's waist.

Choice D reason: Pivoting on the foot farthest from the bed may cause the client to lose balance and fall. The nurse should pivot on the foot closest to the bed and guide the client to turn and sit on the chair.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 125/85 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who needs to increase vitamin C intake to promote wound healing. Which of the following foods should the nurse recommend as the best source of vitamin C?

A nurse is caring for a client who speaks a different language than the nurse and is 5 hours postoperative. Which of the following actions should the nurse take to determine the client's level of pain?

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.)

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

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?

A nurse is preparing to insert an indwelling urinary catheter and is verifying the client’s express consent for this procedure. Which of the following actions should the nurse take?