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 A

Explanation

Choice A rationale

Flexing hips and knees when assisting the client to a standing position uses proper body mechanics, reducing the risk of injury to both the nurse and the client. It provides a stable base of support during the transfer.

Choice B rationale

Pivoting on the foot farthest from the bed when assisting the client into the chair is incorrect. The nurse should pivot on the foot closest to the bed to maintain balance and control during the transfer.

Choice C rationale

Standing on the client's stronger side when moving the client into the chair is incorrect. The nurse should stand on the client's weaker side to provide support and prevent falls.

Choice D rationale

Raising the bed to waist level before moving the client is incorrect as it may not provide the best ergonomic position for the transfer. The bed should be at a height that ensures the nurse’s safety and facilitates the client's movement.

A. Respiratory rate 10/min B. Pulse oximetry 88% on room air C. Blood pressure 99/46 mm Hg D. Morphine 10 mg administered subcutaneously

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.

Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.

Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.

Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.

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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

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Correct Answer is A

Explanation

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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.)