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 C
Explanation
Choice A reason: Aspirating for a blood return before depressing the plunger is not recommended when administering enoxaparin. Enoxaparin is given subcutaneously, and aspiration is not necessary for subcutaneous injections. Aspiration can cause tissue damage and increase the risk of bleeding.
Choice B reason: Inserting the needle at a 45-degree angle is appropriate for subcutaneous injections if the patient has limited subcutaneous tissue. However, for enoxaparin, the preferred angle is 90 degrees to ensure the medication is delivered into the subcutaneous tissue.
Choice C reason: Not expelling the air bubble in the prefilled syringe is correct. The air bubble in the prefilled syringe of enoxaparin is designed to ensure the entire dose is administered and to prevent leakage of the medication. Expelling the air bubble can result in an incomplete dose.
Choice D reason: Administering the medication 2.54 cm (1 inch) from the umbilicus is correct for subcutaneous injections in the abdomen. However, this statement alone does not address the specific consideration of the air bubble in the prefilled syringe, which is crucial for enoxaparin administration.
Correct Answer is A
Explanation
Choice A reason: Administering the medication over 1 minute is crucial for phenytoin IV administration. Phenytoin should be administered slowly to prevent severe cardiovascular reactions, including hypotension and arrhythmias. The recommended rate is not to exceed 50 mg per minute.
Choice B reason: Diluting the medication with sterile water before injecting is not recommended for phenytoin. Phenytoin should be administered undiluted or diluted with normal saline if necessary. Using sterile water can cause the medication to precipitate.
Choice C reason: Slowing the injection if the medication crystallizes is not an appropriate action. If phenytoin crystallizes, it should not be administered. The nurse should ensure the solution is clear before administration and discard any crystallized medication.
Choice D reason: Following the injection with sterile water is not necessary. Phenytoin does not require a flush with sterile water after administration. Instead, normal saline can be used to flush the IV line before and after administration to ensure the line is clear.
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