A nurse is caring for several clients on a medical-surgical unit. Which of the following client care situations requires the nurse to complete an incident report?
The nurse disagrees with the nurse manager about inadequate staffing.
A staff member has not arrived at the facility to work an assigned shift.
A client tells the nurse that his dentures are missing.
The nurse discovers that the client does not have advanced directives.
The Correct Answer is C
An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone— patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required ⁴. In this case, the client's missing dentures would be considered a complaint and would require the nurse to complete an incident report.
The other options do not require an incident report. Disagreeing with the nurse manager about inadequate staffing [a], a staff member not arriving at the facility to work an assigned shift [b], and discovering that the client does not have advanced directives [d] are not situations that would require an incident report according to the information provided in my sources.
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Correct Answer is B
Explanation
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This adherence to an essential ethical principle is Non-maleficence. Non-maleficencerefers to the principle of "do no harm" and requires healthcare providers to avoid causing harm to their patients.
Option A refers to wrongdoing or misconduct and is not applicable in this situation.
Option C refers to truthfulness and honesty, but it is not the primary principle being demonstrated in this situation.
Option D refers to fairness and equality, but it is not the primary principle being demonstrated in this situation.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: Obtaining consent directly from a client who has received IV morphine sulfate is invalid due to impaired cognitive function. Morphine acts on mu-opioid receptors in the central nervous system, reducing alertness, memory retention, and decision-making capacity. Informed consent requires full comprehension of risks, benefits, and alternatives. Morphine’s sedative effects compromise this standard. Normal Glasgow Coma Scale should be 15 for full alertness; sedation lowers this, rendering consent legally and ethically unsound.
Choice B rationale: The nurse cannot legally sign the consent on behalf of the client, even if the client is acknowledged. This violates the principle of autonomy and informed decision-making. The nurse’s role is to witness the client’s signature, not substitute it. Morphine impairs cognition, and any consent obtained under its influence is invalid. Legal standards require that the client be alert, oriented, and capable of understanding the procedure. Proxy consent must be pursued if capacity is compromised.
Choice C rationale: When a client is under the influence of opioids and lacks decision-making capacity, consent must be obtained from a legally authorized representative, such as a relative or healthcare proxy. Morphine alters consciousness and impairs executive function, making the client temporarily incompetent. Legal surrogates are empowered to make healthcare decisions in such cases. This ensures ethical compliance and protects patient rights. The nurse must verify documentation of proxy authority before proceeding with consent.
Choice D rationale: Delaying the procedure may be necessary if no authorized proxy is available, but it is not the first action. The priority is to identify and contact a legally authorized representative to obtain valid consent. Delays can compromise care, especially in urgent surgical cases. The nurse must act promptly to secure proxy consent, ensuring procedural integrity and patient safety. Only if no proxy is reachable should delay be considered, with documentation of rationale.
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