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 A
Explanation
"I should discuss this document with my family after I sign it"
Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.
"I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.
"An attorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.
"My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.
Correct Answer is ["C","D","E"]
Explanation
When managing oxygenation for a client in a PACU, the nurse should take several actions. The nurse should add a humidifier to the oxygen device to help prevent dryness of the nasal passages¹.
The nurse should also encourage the client to perform deep breathing exercises to promote oxygenation¹.
Additionally, the nurse should examine the client's nail beds for signs of cyanosis, which can indicate inadequate oxygenation¹.
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