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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When resolving a conflict with an assistive personnel (AP) who refuses a client assignment, it would be appropriate for the nurse to say "I need to talk to you about the unit policies regarding client assignments." This comment addresses the issue directly and professionally and provides an opportunity for the nurse to clarify the unit policies and expectations.
Option A is accusatory and unprofessional.
Option B may be necessary at some point, but it should not be the first response.
Option C is also accusatory and unprofessional.
Correct Answer is ["B","C","E"]
Explanation
Discussing clients at the table in the cafeteria [b], disposing of written report sheets into the facility trash receptacle [c], and sharing a personal password with a coworker [e] are all actions that jeopardize client confidentiality. Client information should be kept private and secure at all times. Discussing clients in public places or disposing of client information in an unsecured manner can result in unauthorized access to confidential information. Sharing personal passwords can also compromise the security of client information.
The other options do not jeopardize client confidentiality. Removing client information from fax machines immediately [a] helps to prevent unauthorized access to confidential information. Giving verbal reports at change of shift in a designated conference room [d] is a standard practice that allows for the secure transfer of client information between healthcare providers.
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