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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Maintain low-level lights in common areas.Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.
B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.
C. Confront the client regarding inappropriate behavior.Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.
D. Use symbols in the communal room signage.Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.
Correct Answer is D
Explanation
Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.
No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.
Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.
Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.
Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.
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