A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

A nurse observes a client vomiting after receiving an oral pain medication.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm.

A nurse discovers that an electronic IV pump.delivered twice the prescribed amount of fluid to a client.

A nurse discovers that a client's family member has administered a PCA dose.

Answer and Explanation

The Correct Answer is C

This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.

The following examples may not require an incident report:

A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.

A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.

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Correct Answer is A

Explanation

Cotton underwear is recommended for individuals with UTIs because it allows better air circulation and helps keep the genital area dry. This can prevent the growth of bacteria and reduce the risk of further infection.

Drink orange juice daily for 3 to 4 weeks: While hydration is important for overall health, there is no specific recommendation to drink orange juice or any specific juice for the treatment of a UTI. It is generally recommended to increase fluid intake, particularly water, to help flush out the bacteria from the urinary system.

Take the prescribed antibiotic until manifestations are gone: This instruction is correct. It is important for the client to take the full course of the prescribed antibiotic as directed by their healthcare provider, even if symptoms improve before completing the entire course. This helps ensure complete eradication of the bacteria and reduces the risk of antibiotic resistance.

Restrict fluid intake to 1 L per day: Adequate fluid intake is important for UTI management as it helps flush out bacteria from the urinary system. Restricting fluid intake to 1 liter per day is not recommended and may not provide sufficient hydration. It is generally advised to drink plenty of water and other fluids throughout the day.

A. Provider's progress notes B. Nursing care plan C. Incident report D. Controlled substance inventory record

Correct Answer is C

Explanation

An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.

The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.

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A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is C

Explanation

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