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 C
Explanation
Choice A reason: This is not the correct answer because greenish-yellow drainage is a normal color for gastric secretions and does not indicate a problem.
Choice B reason: This is not the correct answer because a report of hunger is common for a client with an NG tube and does not require intervention.
Choice C reason: This is the correct answer because gastric contents in the air vent mean that the NG tube is clogged or kinked and needs to be flushed or replaced. This is the correct answer because it indicates that the NG tube is not functioning properly and could cause aspiration or infection. The other findings are expected or normal for a client with an NG tube.
Choice D reason: This is not the correct answer because abdominal distention is a common reason for placing an NG tube and should improve with gastric decompression.
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.
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