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 C

Explanation

Explanation

C. The client has developed difficulty ambulating

The information about the client's difficulty ambulating is relevant to the interprofessional team because it may require input and collaboration from various healthcare professionals to address and manage the client's mobility issues. This information helps the team understand the client's current condition and plan appropriate interventions.

The client having state-sponsored health insurance in (option A) is incorrect because it is not directly relevant to the interprofessional team meeting unless it specifically impacts the client's healthcare options, resources, or access to care. However, it may be important to know for insurance-related discussions or considerations, depending on the purpose of the team meeting.

The client's next dressing change being scheduled in 4 hours in (option B) is incorrect because it is important information for the nurse's own clinical responsibilities, but it may not be directly relevant to the broader interprofessional team meeting unless it has implications for the client's overall care plan or requires input from other team members.

The frequency of the client's vital sign checks being every 8 hours in (option D) is incorrect because it is important for the nurse's routine monitoring and care, but it may not be the primary focus of the interprofessional team meeting unless there are specific concerns or changes in the client's vital signs that need to be addressed collaboratively.

In summary, the nurse should include information about the client's difficulty ambulating during the interprofessional team meeting, as it helps inform the team's discussions, interventions, and plans regarding the client's mobility and potential impact on their overall care.

A. Maintain low-level lights in common areas. B. Give the client several meal options at lunchtime. C. Confront the client regarding inappropriate behavior. D. Use symbols in the communal room signage.

Correct Answer is D

Explanation

A.Maintain low-level lights in common areas.Inadequate lighting can contribute to disorientation and falls. Well-lit areas with natural or soft lighting are preferable.

B.Give the client several meal options at lunchtime.Too many choices can be overwhelming and increase confusion. Instead, limiting choices (e.g., offering just two meal options) is a better approach.

C.Confront the client regarding inappropriate behavior.Confrontation can increase agitation and distress. Instead, redirection and gentle guidance are more effective strategies.

D. Use symbols in the communal room signage.Clients experiencing confusion and memory loss benefit from visual cues and simple, clear communication. Using symbols (such as pictures of a toilet for the restroom or a plate for the dining area) can help them navigate the environment more easily and reduce frustration.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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