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 {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The correct answer is Constipation / Opioid use.

Constipation is a common side effect of opioid use. The client is receiving oxycodone for pain management, which can slow down the digestive system, leading to constipation.

Pressure injuries, also known as pressure ulcers or bedsores, are a risk due to prolonged immobility. This is especially relevant for a client who is postoperative and has limited movement. However, this was not selected as the primary condition based on the given clues.

Hypoglycemia (low blood sugar) is not directly indicated by the client's current medications or conditions. The client is receiving IV dextrose, but there is no indication of a risk of hypoglycemia in the provided information.

Confusion can occur in clients with cognitive impairments or due to medication side effects, but it is not specifically indicated as a primary risk in this case.

Dysrhythmias (abnormal heart rhythms) can be caused by imbalances in potassium or sodium levels, among other factors, but there is no evidence of such imbalances or related symptoms in this client’s case.

A. Place the client's arms above her head prior to logrolling. B. Place the client in semi-Fowler's position prior to logrolling. C. Place the bed in the lowest position before logrolling the client. D. Place a pillow between the client's legs prior to logrolling.

Correct Answer is D

Explanation

Choice A rationale

Placing the client's arms above her head prior to logrolling can cause discomfort and injury, especially after spinal surgery. Arms should be kept at the sides to maintain alignment.

Choice B rationale

Placing the client in semi-Fowler's position before logrolling is incorrect. The semi-Fowler's position is not stable for logrolling and does not align the spine correctly for safe movement.

Choice C rationale

Placing the bed in the lowest position before logrolling can make the process more difficult and unsafe. The bed should be at a height that allows proper body mechanics for the caregiver.

Choice D rationale

Placing a pillow between the client's legs prior to logrolling helps maintain spinal alignment and prevents twisting of the spine, which is crucial after a laminectomy.

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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

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is caring for a client who is postoperative following a laminectomy.Which of the following actions should the nurse take when repositioning the client?

Correct Answer is D

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.)