A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form?
"Incident report completed. A copy will be placed in the client's medical record.
"Prescribed dressing change was accidentally omitted during the previous shift."
"A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow."
"Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled.
The Correct Answer is B
A. "Incident report completed. A copy will be placed in the client's medical record." This statement indicates the completion of the incident report but lacks essential information about what incident occurred. It does not provide details necessary for understanding the nature of the incident.
B. "Prescribed dressing change was accidentally omitted during the previous shift." This statement clearly identifies the nature of the incident, stating that a prescribed dressing change was missed. It provides factual information without assigning blame, which is appropriate for an incident report.
C. "A nurse accidentally omitted a prescribed dressing change. Will notify the provider tomorrow." While this statement acknowledges the omission, it lacks details about the incident and focuses on future actions rather than accurately documenting what occurred.
D. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." This statement does not accurately represent the situation. It implies that the dressing change was not completed due to the dressing not appearing soiled, which may not be the case. It does not acknowledge the omission of the prescribed dressing change.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Place the patch on your upper arm": Transdermal scopolamine patches are typically applied behind the ear, not on the upper arm. Placing the patch behind the ear allows for optimal absorption of the medication through the skin.
B. "Replace a dislodged patch onto the same location": If the patch becomes dislodged, it should not be reattached. Instead, a new patch should be applied to a different area behind the ear to prevent skin irritation and ensure continuous drug delivery.
C. "Apply the patch prior to traveling": This is the correct instruction. Transdermal scopolamine patches are applied to the skin at least 4 hours before travel to prevent motion sickness during the journey. Applying the patch in advance allows time for the medication to be absorbed into the bloodstream and provide effective symptom relief.
D. "Store unused patches in the refrigerator": Transdermal scopolamine patches do not typically require refrigeration. They should be stored at room temperature in a cool, dry place. Refrigeration may alter the integrity of the patch and affect its effectiveness.
Correct Answer is D
Explanation
A. Cover the cord with the upper edge of the diaper: Placing the diaper below the umbilical cord stump allows air to circulate around the area, promoting drying and preventing irritation. Covering the cord stump with the upper edge of the diaper may trap moisture and increase the risk of infection.
B. Apply petroleum jelly around the cord with every diaper change: Applying petroleum jelly or any other substance to the umbilical cord stump is not recommended as it can interfere with the natural drying process. Keeping the area dry promotes quicker healing and reduces the risk of infection.
C. Report minor bleeding when the cord's stump falls off: It is normal for a small amount of bleeding to occur when the umbilical cord stump falls off. However, ongoing bleeding or excessive bleeding should be reported to the healthcare provider. Reporting minor bleeding when the stump falls off is unnecessary as it is considered a normal part of the healing process.
D. Wash the area around the base of the cord with water: Cleaning the area around the base of the cord with water helps to prevent infection and promotes healing. It is essential to keep the area clean and dry to avoid bacterial growth. Using water alone is sufficient for cleansing, and there is no need to use soap or other products that may irritate the delicate skin.
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