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 B
Explanation
Stomatitis is an inflammation of the oral mucosa, which can cause pain, discomfort, and difficulty eating. To manage stomatitis, clients should consume soft, bland foods that are easy to chew and swallow, such as cooked vegetables, mashed potatoes, and oatmeal.
Acidic, spicy, or crunchy foods should be avoided. Using lemon glycerin swabs can irritate the oral mucosa, so they should not be used.
Mouthwashes containing alcohol can cause further irritation, so they should also be avoided. Eating foods high in vitamin B12 can be helpful for preventing stomatitis, but it is not an appropriate intervention for managing an existing case of stomatitis.
Correct Answer is D
Explanation
In this scenario, the nurse disclosed sensitive medical information about the client's diagnosis to someone who is not directly involved in the client's care or treatment. This disclosure violates the client's right to privacy and confidentiality.
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