A nurse is reinforcing teaching with a group of newly licensed nurses about completing an incident report. For which of the following situations should the nurse complete an incident report?
A client decides not to have a colonoscopy after signing the consent form.
A client requests to take a shower in the evening rather than in the morning.
A client has an episode of vomiting after receiving medication for hypertension.
A client's family member becomes short of breath and reports having chest pain.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Withdrawing consent is a client’s legal right. No error or unexpected event occurred, so no incident report is required.
Choice B rationale: Preference for shower timing is a routine care adjustment, not an adverse or unusual event requiring documentation.
Choice C rationale: Vomiting may be a side effect, but unless it causes harm or is unexpected, it doesn’t meet incident report criteria.
Choice D rationale: A medical emergency involving a visitor is unexpected and requires documentation for liability, safety, and institutional response tracking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
If a client is concerned about her privacy during a urinary catheterization procedure, the nurse should close the door and cover the client during the procedure. This action helps to maintain the client's privacy and dignity.
Option A may also be helpful in alleviating the client's concern by providing information about the procedure.
Option B may also be helpful in ensuring that the procedure is performed efficiently.
Option C may not be necessary if the client is not resistant to the procedure.
Correct Answer is ["C","D","F"]
Explanation
Situations that can lead to a tort against a nurse include repeating a rumor about a patient's personal life in a staff meeting, telling friends something unusual about a patient that was noted in the patient's chart, and forcing a patient to take medication against their will. These actions can result in legal action against the nurse for invasion of privacy or battery.
Option A is incorrect because referring a stranger to the patient or their family for details regarding the patient is an appropriate action.
Option Bis incorrect because respecting a patient's right to refuse treatment on religious grounds is an appropriate action.
Option Eis incorrect because placing an alarm on the bed of a patient prone to falling is an appropriate action to ensure their safety.
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