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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
Correct Answer is B
Explanation
When preparing to administer medications, the nurse carefully confirms the drug order and the patient's identity. This is an example of the ethical principle of nonmalfeasance. Nonmalfeasance refers 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.
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