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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.
Correct Answer is A
Explanation
Candidiasis, also known as a yeast infection, commonly presents with symptoms such as a thick, white vaginal discharge. It may also be accompanied by itching, redness, and irritation in the vaginal area. This type of discharge is typically described as resembling cottage cheese in texture. Other symptoms that may occur with candidiasis include burning during urination and discomfort during sexual intercourse.
A hard, painless chancre is a characteristic finding of syphilis, not candidiasis. Frothy, malodorous discharge is commonly associated with bacterial vaginosis, not candidiasis.
Feeling of pelvic heaviness is more commonly associated with conditions like pelvic organ prolapse or uterine fibroids, and is not specific to candidiasis.
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