A nurse is caring for a group of clients. For which the following situations should the nurse complete an incident report?

A client receives regular insulin 1 hr after a meal.

A client refuses to get out of bed.

A client was scheduled to be discharged 2 hr ago.

A client receives an antibiotic 30 min after the scheduled time.

Answer and Explanation

The Correct Answer is A

A. A client receives regular insulin 1 hr after a meal: Administering insulin outside the recommended timing can cause hypoglycemia or other adverse effects. This medication error is a reportable event, requiring completion of an incident report for documentation and quality improvement.

B. A client refuses to get out of bed: Patient refusal of activity or care is part of routine nursing documentation and does not constitute an incident that requires a formal report unless it results in harm.

C. A client was scheduled to be discharged 2 hr ago: A delayed discharge is an operational issue rather than a clinical incident. It should be addressed in workflow review but does not require an incident report.

D. A client receives an antibiotic 30 min after the scheduled time: A slight delay in routine medication administration is typically documented in the medical record but does not usually meet the threshold for an incident report unless it results in harm or adverse effects.

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 A

Explanation

A. "The pump will not deliver any medication during the lockout period.": The lockout interval is a safety feature that prevents overdose by ensuring the pump cannot deliver additional doses until a set time has passed. Understanding this helps the client use the PCA safely.

B. "I should wait to push the pain button until the pain becomes severe.": PCA is most effective when the client administers medication at the onset of pain rather than waiting for it to become severe, as early administration prevents pain from escalating.

C. "My partner can push the pain button for me if I fall asleep.": Only the client should operate the PCA pump to prevent accidental overdose. Allowing someone else to push the button violates safety protocols.

D. "I will be asked to describe and rate my pain every 8 hours.": Pain assessment should be frequent, especially in the first 24 hours of PCA use, to adjust therapy and monitor effectiveness. An 8-hour interval may not provide timely information to manage pain effectively.

A. "I feel like my heart is skipping beats." B. "I have noticed that I have decreased sexual interest." C. "I have recently lost 7 pounds." D. "I feel less anxious when I am around my friend."

Correct Answer is B

Explanation

A. "I feel like my heart is skipping beats.": Palpitations can occur with some medications, but they are less common with escitalopram. This may warrant further assessment but is not a typical adverse effect of the drug.

B. "I have noticed that I have decreased sexual interest.": Sexual dysfunction, including decreased libido, delayed ejaculation, and anorgasmia, is a well-known adverse effect of selective serotonin reuptake inhibitors (SSRIs) like escitalopram.

C. "I have recently lost 7 pounds.": Weight changes can occur with antidepressants, but mild weight loss is not typically considered a primary adverse effect of escitalopram and may reflect other factors.

D. "I feel less anxious when I am around my friend.": This statement reflects the therapeutic effect of escitalopram in reducing anxiety and improving mood, rather than an adverse effect.

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 the following situations should the nurse complete an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client how to use patient-controlled analgesia with morphine. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is teaching a client who is being treated for depression with escitalopram. Which of the following statements by the client should the nurse identify as an adverse effect?

Correct Answer is B

Explanation

A nurse is mixing NPH insulin and regular insulin prior to administration. Which of the following actions should the nurse take first?

A nurse is caring for a client who received a dose of IV morphine for pain. Which of the following vital signs indicates the client is having an adverse reaction to the medication?

A nurse is preparing to administer IV adenosine to a client. Which of the following effects should the nurse anticipate?

A nurse is caring for a client who is receiving an intravenous potassium infusion and who has a urine output of 10 mL/hr and a blood urea nitrogen of 50 mg/dL (10 to 20 mg/dL). Which of the following actions should the nurse take?

A nurse is assessing a client who has taken omeprazole for over 10 years and recently reported experiencing severe muscle cramps. Which of the following electrolyte imbalances should the nurse consider as possibly contributing to this issue?

A nurse is caring for a client who has an infection and has been taking penicillin. Which of the following statements by the client should the nurse identify as the priority to report to the provider?

A nurse is reviewing the medical history of a client prior to medication administration and notes a history of an anaphylactic reaction to penicillin. The nurse should identify that which of the following medications is contraindicated for this client?