A nurse is caring for a group of clients. Which of the following situations requires an incident report?

A client experiences a seizure.

A client vomits after receiving an oral medication.

A client receives their insulin 1 hr before scheduled.

A client receives their meal tray 20 min late.

Answer and Explanation

The Correct Answer is C

Incident reports are documented for incidences that are likely to cause adverse outcomes for the clients or healthcare professionals and, therefore, their occurrence needs to be mitigated. In this case, wrong timing for medications such as insulin may lead to overdose with subsequent hypoglycemia which is detrimental

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Correct Answer is C

Explanation

A- Confirming with another nurse ensures right dosage is not necessary. Dosage should be confrimed with the prescription and proper calculation

B-Verification with the administration record ensures that the prescribed medication is the one given. This is important as it ensures that the client receives the right medications for the illness. However, it is not part of the rights of medication administration

C-Use of 2 identifiers ensures right client which is part of the rights of medication administration

D-Documenting full names is important for record-keeping but not part of the rights of medication administration

A. Blood pressure 140/86 mm Hg B. Temperature 37.50 C (99.50 F) C. Heart rate 65/min D. Respiratory rate 10/min

Correct Answer is D

Explanation

Respiratory rate of 10/min indicates respiratory depression which a potential adverse effect of morphine. Opioids suppress the central respiratory centers leading to respiratory depression. Use of two opioids increases their levels in blood raising the risk of respiratory depression even higher which is fatal.
A.- Elevated blood pressure is not directly related to morphine use . Could be an indication of pain
B.-Normal temperature
C.-Normal heart rate

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A nurse is caring for a group of clients. Which of the following situations requires an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a medication to a client. Using the rights of medication administration. Which of the following actions should the nurse take to ensure the right medication is administered to the client?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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