A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
The nurse identifies a broken piece of equipment.
The nurse has a disagreement with the nursing supervisor about inadequate staffing.
A staff member does not show up to work her assigned shift.
A client discovers that his dentures are missing.
The Correct Answer is D
Choice A reason:
The statement “The nurse identifies a broken piece of equipment” is important for safety and should be reported to the appropriate department for repair or replacement. However, it does not typically require an incident report unless the broken equipment caused harm or had the potential to cause harm to a patient. Incident reports are generally used to document events that are not consistent with the routine operation of the healthcare unit or the standard care of a patient.
Choice B reason:
The statement “The nurse has a disagreement with the nursing supervisor about inadequate staffing” reflects an internal issue that should be addressed through appropriate channels, such as a staff meeting or a discussion with human resources. It does not typically require an incident report unless the disagreement led to a situation that compromised patient safety or care. Incident reports are meant to document events that directly affect patient care and safety.
Choice C reason:
The statement “A staff member does not show up to work her assigned shift” is a staffing issue that should be managed by the nursing supervisor or the staffing coordinator. While it can affect the workflow and staffing levels, it does not usually require an incident report unless it directly impacts patient care or safety. Incident reports are used to document specific events that deviate from standard care practices and have the potential to harm patients.
Choice D reason:
The statement “A client discovers that his dentures are missing” is a situation that requires an incident report. The loss of a client’s personal belongings, especially something as essential as dentures, can significantly impact the client’s well-being and quality of care. Documenting this incident helps to investigate the circumstances, prevent future occurrences, and ensure that appropriate measures are taken to address the client’s needs. Incident reports are crucial for tracking and addressing issues that affect patient care and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administer a test dose first
Administering a test dose is not typically required for theophylline. Theophylline dosing is usually based on the patient’s weight and serum theophylline levels. A test dose is more commonly associated with medications that have a high risk of allergic reactions or require desensitization protocols, which is not the case with theophylline.
Choice B reason: Infuse the medication with an IV pump
Using an IV pump to infuse theophylline is essential to ensure accurate and controlled delivery of the medication. Theophylline has a narrow therapeutic range, and precise dosing is crucial to avoid toxicity. An IV pump allows for consistent infusion rates, reducing the risk of adverse effects. This is the most appropriate action for the nurse to take.
Choice C reason: Cover the IV container with dark paper
There is no need to cover the IV container with dark paper when administering theophylline. Theophylline is not light-sensitive, so this precaution is unnecessary. Covering IV containers is typically done for medications that degrade when exposed to light, such as certain antibiotics and chemotherapy agents.
Choice D reason: Infuse the medication at 35 mg/min
Infusing theophylline at a rate of 35 mg/min is excessively high and could lead to severe toxicity. The infusion rate for theophylline should be carefully calculated based on the patient’s weight and serum levels, and it is typically much lower than 35 mg/min. Rapid infusion can cause serious side effects, including arrhythmias and seizures.
Correct Answer is []
Explanation
Potential Condition: Chorioamnionitis
Chorioamnionitis is an infection of the amniotic fluid, membranes, placenta, and/or decidua. It is often associated with preterm prelabor rupture of membranes (PPROM), especially when there is a prolonged rupture of membranes, as in this case. The client’s symptoms, including a high temperature (38.2°C), elevated heart rate (112/min), and purulent amniotic fluid, strongly suggest an intra-amniotic infection.
Potential Condition: Abruptio Placentae
Abruptio placentae, also known as placental abruption, is the premature separation of the placenta from the uterine wall before childbirth. This condition can lead to significant maternal hemorrhage and jeopardize the well-
being of the fetus. The primary symptoms include vaginal bleeding, abdominal pain, uterine tenderness, and contractions. In severe cases, it can cause maternal shock and fetal distress or death. The client’s symptoms, such as abdominal discomfort and contractions, could be indicative of this condition, but the presence of purulent amniotic fluid and fever makes chorioamnionitis a more likely diagnosis in this scenario.
Potential Condition: Prolapsed Umbilical Cord
A prolapsed umbilical cord occurs when the umbilical cord slips ahead of the fetal presenting part and prolapses into the cervical canal, vagina, or beyond. This is an obstetric emergency because the prolapsed cord can be compressed, cutting off the baby’s blood and oxygen supply. The primary signs include visible or palpable cord at the cervix or in the vagina, and sudden changes in fetal heart rate patterns, such as bradycardia or variable
decelerations. While the client’s fetal heart rate is elevated, there is no indication of a visible or palpable cord, making this condition less likely.
Potential Condition: Preeclampsia
Preeclampsia is a pregnancy-specific condition characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. It can lead to serious complications such as eclampsia, HELLP syndrome, and organ damage. Symptoms include high blood pressure, proteinuria, severe headaches, visual disturbances, and epigastric pain. The client’s history of chronic hypertension and elevated heart rate could suggest preeclampsia, but the absence of high blood pressure and proteinuria in the current assessment makes this diagnosis less likely compared to chorioamnionitis.
Choice A: Prepare to administer gentamicin IV
Gentamicin is an aminoglycoside antibiotic that is often used in combination with other antibiotics to treat chorioamnionitis. It is effective against a broad range of bacteria that could be causing the infection. Administering gentamicin IV can help manage the infection and prevent further complications for both the mother and the fetus34.
Choice B: Obtain a prescription for hydraclone PO
Hydraclone is not a standard treatment for chorioamnionitis. The primary treatment involves antibiotics to manage the infection. Therefore, this option is not appropriate in this scenario.
Choice C: Place the client in the Trendelenburg position
The Trendelenburg position, where the patient is laid flat on their back with their feet higher than their
head, is not indicated for chorioamnionitis. This position is typically used in cases of umbilical cord prolapse to relieve pressure on the cord.
Choice D: Place the client in a quiet environment
While placing the client in a quiet environment may help with overall comfort, it does not directly address the infection or its complications. Therefore, it is not a primary action in managing chorioamnionitis.
Choice E: Educate the client on the process of inducing labor
Inducing labor may be necessary in cases of chorioamnionitis to reduce the risk of complications for both the mother and the baby. Prompt delivery is often recommended once the infection is diagnosed to prevent further maternal and fetal morbidity.
Parameters to Monitor:
Choice A: Uric acid levels
Monitoring uric acid levels can help assess the client’s overall metabolic state and detect any potential complications such as preeclampsia, which can coexist with chorioamnionitis.
Choice B: Deep tendon reflexes
Deep tendon reflexes are typically monitored in cases of preeclampsia to assess for hyperreflexia, which is not relevant in the context of chorioamnionitis.
Choice C: Dysfunctional labor
Monitoring for dysfunctional labor is important but not specific to chorioamnionitis. The primary focus should be on managing the infection and monitoring maternal and fetal well-being.
Choice D: Maternal body temperature
Maternal body temperature is a critical parameter to monitor in cases of chorioamnionitis. An elevated temperature is a key indicator of infection, and monitoring it helps assess the effectiveness of the treatment.
Choice E: Inadequate uterine reduction
Inadequate uterine reduction is not a relevant parameter in the context of chorioamnionitis. The focus should be on monitoring signs of infection and maternal and fetal well-being.
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