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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Atropine: Atropine is not used to treat benzodiazepine toxicity. It is primarily indicated for treating bradycardia, organophosphate poisoning, and certain types of poisoning causing excessive muscarinic effects.
B. Flumazenil: Flumazenil is a benzodiazepine receptor antagonist and is used to reverse the sedative effects of benzodiazepine overdose or toxicity. It competitively inhibits the action of benzodiazepines at the receptor site, reversing their effects.
C. Naloxone: Naloxone is a medication used to reverse opioid overdose by competitively binding to opioid receptors and displacing opioid agonists. It is not effective in treating benzodiazepine toxicity.
D. Activated charcoal: Activated charcoal is used to absorb ingested toxins in cases of poisoning. However, it is not effective in treating benzodiazepine toxicity because benzodiazepines are not effectively absorbed by activated charcoal.

A. "Empty your ostomy pouch when it is half full." B. "Notify the provider if your stoma becomes pink and moist. C. "Use a moisturizing soap to cleanse your stoma." D. "Apply sterile gloves when changing your ostomy pouch."

Correct Answer is A

Explanation

Answer: A

Rationale: A) "Empty your ostomy pouch when it is half full.": This instruction is essential to prevent the pouch from becoming too heavy, which can cause leakage or discomfort. Regular emptying also helps maintain the integrity of the pouching system and prevents leaks.

B) "Notify the provider if your stoma becomes pink and moist.": While it's crucial to monitor the stoma's appearance for signs of complications, a pink and moist stoma typically indicates healthy tissue. This instruction may cause unnecessary concern for the client.

C) "Use a moisturizing soap to cleanse your stoma.": Moisturizing soap is not recommended for stoma cleansing, as it may leave a residue that interferes with the pouch's adhesion and can lead to skin irritation. Instead, the client should use warm water and a mild, non-moisturizing soap.

D) "Apply sterile gloves when changing your ostomy pouch.": While hand hygiene is essential when managing an ostomy, sterile gloves are not necessary for routine pouch changes. Clean, non-sterile gloves or thorough handwashing with soap and water are sufficient to prevent infection.

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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?

Nursing Test Bank

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