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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.
Choice B rationale
Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.
Choice C rationale
Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.
Choice D rationale
Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.
Correct Answer is B
Explanation
Choice A rationale
The sides of the sling are not designed for the client to hold on to, as this could compromise safety. Clients should keep their hands away to prevent injury and ensure stability during the transfer.
Choice B rationale
Mechanical lifts are designed to assist clients who cannot help themselves due to limited mobility or strength. This device ensures safe transfer without requiring the client's physical assistance, reducing the risk of injury to both the client and the caregiver.
Choice C rationale
Positioning the sling's lower end below the client's calves is incorrect. The correct positioning is beneath the client's thighs and around the upper body to provide adequate support during the lift. Incorrect placement can lead to discomfort or injury.
Choice D rationale
Mechanical lifts do not require the client to use upper body strength. These devices are specifically intended to aid clients with minimal or no ability to support themselves, thereby minimizing physical exertion from the client.
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