A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Correct answer: C

A.Opening the dampers of fireplaces: This instruction is not appropriate during an outdoor chemical disaster. Opening the dampers of fireplaces can allow contaminated air from outside to enter the home, increasing the exposure to hazardous substances. It is best to avoid introducing outdoor air into the home during such incidents.

B. Turning on ceiling fans and air conditioners: This instruction is also not recommended during an outdoor chemical disaster. Turning on fans and air conditioners can potentially circulate contaminated air within the home, leading to increased exposure. It is best to turn off fans and air conditioners during such incidents and focus on evacuating the area.

C. Covering heat registers with plastic and tape: Covering heat registers with plastic and tape would help seal off potential entry points for contaminated air, reducing the risk of indoor contamination.

D.In the case of a nearby outdoor chemical disaster, it is usually safer to stay indoors and seal the home rather than exit, as going outside could increase exposure to the harmful chemicals.

An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.

In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.

The other examples listed may require further actions but may not necessarily require an incident report:

1. A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
2. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
3. A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.