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 B

Explanation

Giving the client the opportunity to participate in decision-making regarding the timing of treatments and procedures respects their autonomy and allows them to have some control over their care.

Be honest with the client about the prognosis: By providing accurate and honest information, the nurse respects the client's right to know and be involved in decision-making regarding their healthcare.

Provide privacy during client care procedures: Respecting the client's privacy during care procedures allows them to maintain a sense of dignity and control over their body.

Administer pain medication on a routine schedule: Ensuring that pain medication is provided on a routine schedule allows the client to have control over their pain management and helps maintain their comfort and quality of life

A. Nursing care plan B. Incident report C. Provider's progress notes D. Controlled substance inventory record

Correct Answer is B

Explanation

An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.

A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.

The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.

The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes

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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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Explanation

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Correct Answer is B

Explanation

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