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 D
Explanation
A. Wire cutters:
Wire cutters are typically not necessary for postoperative care following a thoracotomy with chest tube placement. They are more commonly used in situations such as removing orthopedic hardware or cutting wires in emergency situations. Therefore, wire cutters are not essential equipment for this particular procedure.
B. Montgomery straps:
Montgomery straps are adhesive strips used to secure dressings or bandages without the need for tape. While they can be useful in some postoperative situations, they are not specifically required for a thoracotomy with chest tube placement.
C. Tracheostomy tray:
A tracheostomy tray contains equipment necessary for performing tracheostomy care, such as sterile gloves, tracheostomy tubes, and suctioning equipment. It is not directly related to thoracotomy or chest tube care post op.
D. Padded clamp:
A padded clamp, or chest tube holder, is a device used to secure chest tubes in place and prevent them from being accidentally dislodged. It is an essential piece of equipment for postoperative care following a thoracotomy with chest tube placement, as it helps maintain the integrity of the chest tubes and prevents complications such as air leaks or pneumothorax.
Correct Answer is B
Explanation
A. Preeclampsia: Preeclampsia is not a contraindication for the administration of misoprostol for induction of labor. In some cases, it may even be indicated to prevent complications associated with continuing the pregnancy.
B. Transverse fetal lie: A transverse fetal lie, where the baby is positioned sideways in the uterus, is a contraindication for the administration of misoprostol for induction of labor. Misoprostol is contraindicated when the fetal presentation is not cephalic (head down) due to the risk of complications, including cord prolapse.
C. Post-term pregnancy: Misoprostol is commonly used for induction of labor in post-term pregnancies, where the pregnancy has extended beyond 42 weeks. It helps initiate uterine contractions to stimulate labor and reduce the risk of complications associated with prolonged gestation.
D. Intrauterine growth restriction: Intrauterine growth restriction is not a contraindication for the administration of misoprostol for induction of labor. In such cases, the decision to induce labor would depend on various factors related to fetal well-being and maternal health.
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