A nurse is preparing to collect data from a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.)

Answers questions asked by the nurse

Plays with toys in the examining room

Makes eye contact with the nurse

Allows the nurse to touch him on the arm

Sits on his parent's lap when the nurse enters the room

Answer and Explanation

Correct Answer : A,C,D

A. Answers questions asked by the nurse: Responding verbally shows the child is engaged and able to understand and participate in the interaction, indicating readiness to cooperate during the assessment.

B. Plays with toys in the examining room: While playing indicates comfort in the environment, it may also reflect distraction or avoidance rather than readiness to cooperate with the nurse’s instructions. Play alone is not a reliable indicator of cooperation.

C. Makes eye contact with the nurse: Eye contact demonstrates attention and willingness to engage with the nurse, which is a positive sign that the child is prepared to follow directions during data collection.

D. Allows the nurse to touch him on the arm: Tolerating touch shows trust and comfort with the nurse’s presence and interventions, signaling the child is ready to participate in the assessment.

E. Sits on his parent's lap when the nurse enters the room: Sitting on a parent’s lap may indicate the child is seeking comfort and security rather than being ready to cooperate independently. This behavior alone does not confirm readiness for assessment.

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Correct Answer is C

Explanation

A. Nursing care plan: The care plan outlines planned interventions and goals for the client’s care. It is not the appropriate place to document medication errors, as it is intended for ongoing care rather than reporting incidents or deviations from standard practice.

B. Provider's progress notes: While the provider should be notified of the error, documenting it in progress notes alone does not fulfill institutional or legal requirements for reporting medication errors. Progress notes are primarily for client assessment and treatment updates.

C. Incident report: An incident report is the correct location to document a medication error. It provides a formal record for quality improvement, risk management, and legal purposes. Documentation should be factual, timely, and include details of the error and immediate actions taken.

D. Controlled substance inventory record: This record tracks the administration and count of controlled substances. While the codeine component must be accounted for in the inventory, the inventory itself does not replace the need for an incident report to document the error comprehensively.

A. A client has difficulty voiding following the removal of an indwelling catheter B. A client reports nausea following the administration of morphine. C. A client who has type 2 diabetes mellitus did not eat their breakfast D. A client's arm is edematous at the peripheral IV site.

Correct Answer is D

Explanation

A. A client has difficulty voiding following the removal of an indwelling catheter: Difficulty voiding can be a common, expected postoperative or post-catheterization occurrence. It requires nursing interventions but does not warrant an incident report unless it results in harm or an adverse outcome.

B. A client reports nausea following the administration of morphine: Nausea is a known and common side effect of opioid medications like morphine. Monitoring and providing antiemetics are appropriate, but this event is anticipated and does not require an incident report.

C. A client who has type 2 diabetes mellitus did not eat their breakfast: Missing a meal may affect blood glucose control but is not considered a reportable incident. Nursing actions would include monitoring glucose and providing alternatives, rather than filing an incident report.

D. A client's arm is edematous at the peripheral IV site: Edema at an IV site may indicate infiltration, phlebitis, or extravasation, which are complications of intravenous therapy. Because it is a preventable or unexpected adverse event, it must be documented in an incident report to inform quality improvement and patient safety measures.

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A nurse is preparing to collect data from a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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