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 receives burns from a heating pad.

A client reports being dissatisfied with the temperature of the meals provided.

A client becomes disoriented and falls out of bed.

A client's visitor becomes dizzy and faints in the client's room.

A client is unable to afford the physical therapy that the provider recommends.

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.

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Correct Answer is C

Explanation

Choice A rationale

Turning the client on their back during seizures is not recommended as it can obstruct the airway and increase the risk of injury. Positioning on the side is safer to maintain an open airway.

Choice B rationale

Gently restraining the client during seizures can cause injury and is not advisable. It is important to protect the client from harm by clearing the area around them instead.

Choice C rationale

Loosening the client’s clothing during seizures can help ensure they are not restricted and can breathe comfortably. It also reduces the risk of injury from tight or constrictive clothing.

Choice D rationale

Inserting a washcloth or any object into the client’s mouth during seizures is dangerous and can cause choking or damage to the teeth and mouth. The focus should be on ensuring safety without putting objects in the mouth.

A. Use a narrower cuff to repeat the BP measurement. B. Request a prescription for an antihypertensive medication. C. Measure the client's BP in the other arm. D. Deflate the cuff faster when repeating the BP measurement.

Correct Answer is C

Explanation

Choice A rationale

Using a narrower cuff can result in an inaccurate blood pressure reading by providing artificially high values due to increased pressure on a smaller surface area.

Choice B rationale

Requesting a prescription for an antihypertensive medication is premature without verifying the accuracy of the initial blood pressure measurement and considering other factors that might have influenced the reading.

Choice C rationale

Measuring the client's blood pressure in the other arm can help confirm the initial reading. Differences in readings between arms can occur, and a second measurement ensures accuracy and proper assessment.

Choice D rationale

Deflating the cuff faster when repeating the blood pressure measurement can lead to inaccurate readings. The cuff should be deflated at a standard rate to ensure reliability and accuracy in the measurement. .

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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 is reinforcing teaching about seizure management with the family of a client who has a seizure disorder.Which of the following statements by a family member indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery.The client's BP was 126/72 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 C

Explanation

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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.)